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STATE OF NEBRASKA
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<br />WNEN THIS COPY CARRIES THE RAI5ED SEAL OF THE NEBRASKA DEPARTM,�NT OF MEAL7'N �4AIA�A�N ��RVX �,1'T C�RTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE W7TH TME NEB�ASI�"1���' �4� H�'�`h/ AINL�
<br />HUMAN SERVICES, VITAL. RECORDS OFFIC�, WMICH IS THE LEGAL DEPOSITORY Fpf� �AQ'Y�; Glftl��� �� ;;
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<br />LINCOLN, NEBRASKA FIUM�l , �, r ;�
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<br />STATE OF NEBRASKA - DEPARTMENT OF NEAI.TW qND HUMAN SERVICES FINANCE AND SUP�ORT. � 1.
<br />CER7IFICATE OF DEATH '� ^� �''� � 7
<br />1. OECEDENT'S•NAME (FIrS�, Middle, ^ Lagt, Suftix) 2. SEX 3. DATE OF OEATH (Mo., Oay,Yr.)
<br />T,enore A. _Sander Feraale__.,. Ma 21 2010
<br />4. CITY ANp STATE OR TERRITORY, OR FOREIGN COl1NTRV OF BIRTH 5a. AGE-La9t 6irihday 56, UN�ER 1 YEAq 5C. 11NDER 1 �AY 6. DA7E OF BIRTM (Mo., �ay, Vr.)
<br />(Yrs.) MO5. DAYS HOUR3 MINS. �
<br />aruilton Coun�y 104 Sept. 9 1905
<br />7. BOCIAL SECURITY NUMBER 8a. PLACE DF OEATH �
<br />SQF) __ HOSPITAL D lnpatient Q'[E{�g: �NursingHome/17C � „ , ,- � �
<br />� . ...,�__ .. .... - . � � �
<br />9tl:"FX�ILITY•NAM@"(If not Inetltution, give straat end number) � ��
<br />0 ER/Outpetien� q 4acedem's Noma
<br />Hamilta Mannex' C] oan ❑ omB��sPec�ry�
<br />Ba CITV OR TOWN OF DEATH (Include Zip Code) ^� 8d. COUNTY OF'IEATH
<br />Aurara fi8$18 Hamilton
<br />gg. IN81o� CITV UMITS
<br />� vES Q No
<br />ti. FATHER'5-NAME (Firs�, MiddlB, Ld6�, 5u�fiz) 12. MOTHER'S•NAME (Firat, Middle, Maiden 9urname)
<br />Au�ust Ha old Ida Brietenfeldt
<br />_...__.__
<br />13. �VER IN U.S. ARMED FORCES9 Olve dates of service if yes. 14a, INFORMANT-NAME 14b. RELATION5WIP TO DECE�ENT
<br />(Yes,na,orunk) No Jaan Thiel 17aughter
<br />15. METHOb OF OISPO5ITION 18a. LMER-SIGNATURE � i8b. LICENSE N0. iBc. DATE (Mo., �ey, Vc �
<br />C�suria� ❑ ooneuan �E..� �. .c� �J �( .��_ ,, �Q � 114 � 5 / 25 / 2010
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<br />C]C�Bt11df10� DEntombmant �Bd.CEMETERY,CRBMATORY0R07HERLOCATION . CITY/TOWN STA7E
<br />❑ Remavel ❑ Other (5pecify)
<br />Westlaw Memorial Par Cemetery Gx'and Tsl.and, NE.
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<br />17a. Fl1NERA1. HOME NpME AND MAILING ADbHE55 (StreaL City vrTown, Stete) 17b. Zip Code
<br />I,iv�ngston-Sondermann F.H. 601 N. Webb Road, Grand Island, NE. 68803
<br />Aa.RE51DENCE-STA7E � 8b.G0UNTY µ 9c.CITYORTOWN T
<br />Nebraska Haml�Can Aurora
<br />9d. STREE7ANO NuMeER ^ � Be. APT. NO AL ZIP CODE �
<br />1515 Sth Street 68818
<br />10e. MARITAL STATl15 AT TIME OF pEATH Q Mafried U Never Married 10b, NAME OF 5PO115E (Fir6t, Mitldle, Lasl, Sutlix) If wifa, give maiden name.
<br />❑ Maflied, but aepareted �I Widowed C.1 �ivorced ❑ Unknown
<br />Lpuis 5an der (Deceased)
<br />1B. PARTI.Enlertneqhainefevens--disae9e�.iu�uiie:..ofcampllCitlaGC�•ipetdhee�tltlslheA�NC xa.wueiqcmnWr -� � •-AFPROXIMATEINTERVAL
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<br />respiretory arreat, or veniricular librillatlon withoul ahowing �he ellology. DO NOT ABBREVIATE. Enter only one cause an a line. Add additional Ilnes If necessary. �
<br />IMMEpIATE CAl1SE: � oneet to dealh
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<br />IMME�IATECAUSE(Flnal � (e) AZ�. l.l_..��.I C�� I .� G``� _.. i
<br />dlaeaoewcondMianrasuning � CEOF: �onse�todealh
<br />Indeath)
<br />(�'�... i I ( I t
<br />Sequentlally listcondipans.lf (a� ��,lf l l�.-� r�.. 1 � L't 1 v�, � t(��
<br />any,kadingtotheCau6ellatBd pUETO,ORASACONSEQUENCEOF: I onaetipdeath
<br />an Ilne a.
<br />EI1te11hBUN�ERLYINQCAU5E � � 3 �� �
<br />(dleeaeeorin�urythallniNated (�) �I � � �/�-�{Lf�',. �
<br />theevintlro6uqinglndeath) - _......._.._......_...__� ---.-- L.._-__
<br />DUE T0, DR A3 q CONSEQUENCE OF: i onsat to tleetn
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<br />� 8. PAR711.OTHER SIaNIFICANT CONpIT10N5•Gonditions contribming to the death but nol resulting In the underlying cause glvan In PAFT I. �t9. WASME�ICAL EXAMINER
<br />� -� _ �� ��f�q,, O�RYESONERCDNTACTED?
<br />� L � �� ���` ta.MANNERpFD� H 2 1b.IF7RA�ORTATIONINJl1RV c.WASANAl1TOPgyPe�
<br />�, 0. IF FEMALE: � RFORME�?
<br />�NOI preqnen� within past year �a�ural C] Hqmlcide O orivedOperaror .
<br />L7 Passenger � YES �i "NO
<br />❑ Pregnanl at t�me of dealh ❑ Accident0 Pending Investlgetlon ��
<br />O Nal pregnent, but prepnanl within a2 tlays of death ❑ Pedestdan �d. yyERE AUTOPSY FINOINGS AVAILABLE TO
<br />❑ 5uicide ❑ Could nal6a determined
<br />❑Np�,prBqnaN,6utpregnantA3day8totyear6etoredealh • ❑�Ihef(SpeCify) CpMPLETECAUSEOFbEA7H?
<br />rl Unknown if pregnant within the past year __�____ ❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 226. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, tactory, offlce 6uilding, construc(ion sile, etc. (8pecify)
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<br />�22tl.IKIl1RYA7WORK1�.._._. ._.__..___._ .... ........ .. ..._.....-- -......_..............._._.....�_......._._ ......... .. _....__. _.._�
<br />22e. �ESCRIBE HOW INJURY OCCURRED ..
<br />57ATE ZIP COOE
<br />23a.0A7E0FpEATH�M0.,0ay,Yr,) z 2Aa.0ATESIaNE�(Mo.,�ey,Yr.) 24b.TIME0F0EATH
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<br />�� = 23h,Bb.T I¢�JE� (Mo. a, Yr 23' 71ME OF DEATH m ��= 2dc. PRONO�NCEO �EA� �MO., �ay,Yr.) 24d. TIME PRONOUNCE� �EAD�
<br />Ul `1 ! �� ¢ m
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<br />3d, he be I dge, deal ccurred a he time, date and plece $ W� 24e. On ihB baBiB oi eXaminailon and(or Inve&tlgation, In my opinion death ocCUrred al
<br />� g an due ih aug ta�ed. i nature a Title J• � �� p the tlme, date and pIaCB and due to the cause(s) stated, (8ignature and Tltle )♦
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<br />'�, 5.�I�TOBA OU CON7RI9U7ETOTHEDEATH? 28a. � OR6ANORTIS5l1E�ONATIONBEENCON51bERE�9 6h.WA5CONSENTGRANTEO?
<br />❑ YES Q NO �❑ PROBABLY UNKNOWN O YE5 NO No1 Applica6le i126a is NO 0 YE9 0 NO
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<br />� A�PRESS OF CEfiTIFIE (�YSICIAN, CORQNE9'S PWYSICIAN OR COU � TTQRNEy,1 (Type ar Pdnq /�
<br />7. NAME, TITLE ANf]
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<br />�'l, • � UaZ �`�" ta�i � � r�i; �'�ta V2� �.
<br />� 28a.REGIStRAR'S5IGNATURE� / _ 28b.DATEFILBDBYREGISTRAR (Mo.,Day,Yr.)
<br />❑ YES ❑ NO
<br />`-_ _...... . . .._.._ _...........__._�- ..... ... ... .... _-- �'-_
<br />22L LOCATION OF INJURY • 3TREET 8 NUMBER, APT. N0. Cf1YlI'OWN
<br />. Ldbi�t. I .JUN x 2010
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<br />HHS•61 11/03 (55061)
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