|
, '^'`,
<br />STATE OF NEBRASKA �'M�
<br />,,,,-�. � �
<br />WHEN THIS COPY CARRIES THE R.4ISED SEAL OF THE NEBR.4SKA DEPARTMENT pF HEAL1'J�1 � �.�E �'T�'L�S, IT CERTIFIES
<br />THE 13�LOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA�S A��'���MEACAI'�1°� ��'ALTM AND
<br />'i-•,
<br />MUMAN SERVICES, VITAL RECORDS OFFIC�, WHICH IS THE LEGAL DEPOSI�O��`��'1 ��� ti ;� 8�,
<br />� � . y • ; ,�
<br />DATEOFIS$UANCE ��w��� +* r „�`��
<br />5°rA4NL,E1! � � , ;
<br />,�AN A� �0�'',I a�s�s�~an�������raR' ��.
<br />�P,��.M��ur Q� H�.a�.a a�vP :
<br />LINCOLN, NEBRA$KA 2 p 110 016 � "�"�'' ����� � tl.rr `-
<br />� '� '', � ��� . .. _
<br />� , � � ��' � -i' ``, �� """
<br />'�' ��.� � JIJ�"`! � ,�, w r.. TM
<br />"��� , a„ - � , ��� ,
<br />. �. .•. a'�'�y`�.�� 5` ;.Ij�i,lBy,
<br />� STATEOFNEBRASKA-DEPARTILIENTC�H�.'ILTHANDHUMANSERVICESFINANCEAND$UPPOFi �''�' � �'�
<br />CERTIFICATE DF DEA7H "
<br />t. DECEOENT'S•NAME IFirsl, M�tlal�, L�s: _ SutGr1 P. S!X ]. p�TE OF OEATM (Ma.. G�y,Y�.� �� ,
<br />Alexander Clarence Stienike Male January 25, 200�
<br />1. GTY AND STATE OR TEpRITORY, OR FOR610N COUNTRY OF 01pTH :� ��c.lay� E�untl�r Sb. UNpEA 1 YEAR 5c, UNDER i OAY a. oATE oF BIRTH �Mo., Day, Yc�
<br />•'�� 91 MOB. DAY$ NOl1RS MIN5. AU US� .��I� 1915
<br />Minden� Nebraska 8
<br />>. SOCI�L SECUPIiY NUM9ER h PLACE OF �EATM
<br />. _.. . � .._.. ...-._�3"'�f8��-�"`:�... - �. � ---.._ -. __ �. . . .
<br />_ . ._. . . ._ . ..
<br />_..._. ., _ -_.
<br />Y^SPIiAL '3�IriPitMiu .. Q]�g� Nwshq�HomeA.TC �]Me�piaF�lelNry
<br />� !E. FACILIiY•NAM& (il no� InsUtuUon, ylw shre� artd numney
<br />'�7 ERIOmpeli�m 0 Detedvnft Nama
<br />¢ Tiffany Square Care Home ��„ pa�.�csow�ti�
<br />S
<br />� 9c.CITYORTOWNOFDEATH (Ir1CIud�ZipCtldB1 ad.LOUNTYOFDEATM •
<br />W Grand Island 688p3 Hal].
<br />� y�.RES10ENGE•STATE Gb,CWNTY 9SCT'ORTUWN
<br />W
<br />�. Nebraska Hall Grand Is2and ;
<br />E 9tl. STREE'I AND Nl1MBER ee. APT. MO 91. ZIP CODE 9y. INSIDE W7y urnrt5
<br />d 1411 N. Rub St. 68803 X] res o►+o
<br />� f o�. NA(i1TAl ST�TUS AT TIME OR 0lATN Q[ Mlnl�e C] Nw�1 Mrrried �Ob. NAME OF SP0115! (F611, Nlddle, L��I, Sull�p RwU�, piw m�lden n+m�.
<br />� OwrA�o,6ui��p�ni�C OW+dow�a on�.a�w ❑u�k��� Irene Schwartz
<br />m il. FATHEH'S•NAME (Fliet, IAlddla. Litt, 5u111z) 1�. AAOTHEN'$•NAME (Flrst, MICAIe, MaiaM Smnamf)
<br />W Guy Stienike Anna Rasmussen
<br />18.fiVFRIN�.S.ApMEOFORGES?GivId�11li0f6fniC�ilyH. �/I.INFtlpMANT•NAME IIG.qELATI0N6HIPTODECEDENT
<br />cr.,.no.o�unk.� No Irene 5tienike Wife
<br />15• ME7HOD OF DISP051TION 16a. EM&1LMER•�I(iAIATURE t66.l�CEHSENO. tao. �AT! (AAo., D�y. Y�. )
<br />�e��i,i oda�h�, " - ,�./ �/3.�5 lanuasy 27� 2Q07
<br />�CENi1)Ypf1 JEmcmbmmt �Bd.CEMETERY,CREAIFTORVO OTpERLOCATION CITYITOWN , 5TATE
<br />C1Remwal ❑Olh�r�Sp�Clty) Grand Island Cemetery Grand Island� Nehraska
<br />17a FUNERAL HOME NAME AND NAlllN6 ADDRiSS (51�1�1. GIIyDrTOMn, $1i4) 176. 21p COtl!
<br />A fel �'uneral Flame, 1123 West Second� Grand Island� NPbraska 688Q1
<br />AU E F DEATH (&ea inairucliona and erampler)
<br />1& PARTLEnIerPo�Fhejp,qleventa••a�6e�eu,injuria�,orCOmO�i[eliens•dMldlietllyu�eeeln�eeun.DONOT�mutrrmNal�remyWCh�6ca�d�waa�rest, ' �PPPOKIMATEINTEHY1IL
<br />I
<br />respiqtory�r���(,prv�nlrkNarflCdllpqneAllOUHhDringih�ellolppy,ppxOTABBREV�AT�.Enpronl�onscau5lon�lin�.Addiddilondllnlfil�yct8i�ry, �
<br />iMME01A �USE: � � one�t W dealh
<br />. i
<br />I
<br />INNEOI�TECAIlSE�F'Yul (a �
<br />'��a��^�^D DuE7p,OH�SACpNSEOU&NCEOF: i onspirodcilh
<br />ti � / 7 `)n /� I
<br />SpWM1�Ily11�ICEndltlon�,tl �) rQ �u i"� [�[.�c.C/lGd:�/--�4.' � •
<br />nryr,N�elnplonruuNlM�d pUETO,OHABACON5E0UENCEOF: i on nadealh
<br />anllne�,
<br />i
<br />ErYrtlr Vqp�Y1NGCW5�
<br />�dlwMaln�YryMMInIN�Ild f� �
<br />tlrevcnt�iewMnpMdeaN� DUETO,OR�9ACONSEOUENCEOF: i onsotwdauh
<br />U6r
<br />i
<br />(d� I
<br />19. pAqi II. pTHER 516NIFICA CONDITIONS•Condlllon� canlrlMlling la Ihr dulh pYl nW n7u111ny in IM uMu�ylnq cauw piwn in PART I. 19. WAS ME�iCAL ExAMINEH
<br />% � ORCORONERCON
<br />w�f-' 9 ❑ YES a.1f0
<br />� 20.IFFEMALE: 27s.MA�MlERQF�EAiH 216JFTRANSPORTATIONINJURY 41C.WASANAUTDPSYPERFORMEp?
<br />°' ❑ NalpnqnamwunlnpA�lYeur � Naiw.i ONvmicidr Ooriwuopnawr /
<br />� O Pngmnulllm�otdum ❑Aceid�nlC�PeMinghw�dlgmlqn OPuNnqar ❑ YES p��To
<br />. '�' ONolprrqn�m,6ulpreyn�mwilhiMld�ysvldra�h ❑Pedemien Z�d.WEAEAl1TOPSYFINpIN48AVAILAlLlTD
<br />OSuICIA� QCOUIdno�b�ddumin�d ❑pihee 5 11
<br />� � Nolq�pnpnL�u�pNyn�ntl7dayt�oly��b�b��d�iN ( � y � COMPLE7EGUSE�O �
<br />S O UnMnownilproQnaMwithlnih�p�slye�r ❑ YES SdNO
<br />E
<br />s Y'4. OAiE OF INJIIRY (MO., Oay. Yr.) ttC. i1ME OF IN,NRY 2sc. PuCEd► INJUpY•M nom�. iam, eu�e, luia�y, ollicy puildlnp. ton�t�ucpon �N�, „c. (Sp�ellyl
<br />�° m
<br />� 22d.IWUR'/ATWORKT 22l.DESGA�dlHpWINJURYOCCURRED
<br />❑ VE$ ❑ NO
<br />22f.LOCATIONOFINJl1RY•$TREET{NUMBER,APLNO. CfTY/fOWN 6TATE 21PCOpf
<br />p7d.(7ATEpFOEATH IMo..O�y,Yr.� = aa.DATE51GkE01Ma,Dey,Yr.) 2�0.TIMEOF�EATH
<br />�' Januar 25 2Q07 ��� m
<br />� � 7JC. SIGNEO (MO..Dq.Yf.) lx.TIME0F0EATH 71c.PRONOUNCED�EA� IMa,Oay,YC1 Nd.TIMEPR�Nqi1NCE00EAD
<br />a � ,7 n ar 2S� 2007I 6:42 am �„•� m
<br />� 23a.Ta � nnt ol my k�wirl�aq�, 0 � oetun�d �t �M uma, epe �nq piac� F �� 7��. On IM ba�f� W a.�minatlon �nela inveulq�tie�, In my opinlnn dee�h xcuma �t
<br />E� e d due t a uusals) iotetl (91qn�1un �nd Tin� �� B In� Ilm�, Cill �ntl p1aN and du� ta th� c�us�1�) yu��d. (Siynnure and illle 1♦
<br />/ Qi C
<br />25. �TOBACCAUSELONTHI8U7ETOTNE 7 tBe.HA60HGANDRTISSUE�ONAT1oNBEENCON5IDEREGI 286.WA5CON&ENTGPANTEO?
<br />� Y 4 ❑ Np ❑ VROBABL� lT UNKHOWN 0 YE$ ll'NO N01 AppIIG61� II j6� I� NO 0 1'E9 ��
<br />7.N E.iIAEAN0A00RE5SOFLERTIFIEPIPHT5ICIAN,CORONEP'SPHYSILIANOqGppNTYATTORN&YI(Typrpprin�) � � �� � � � �
<br />ohn Wagoner M.D. 800 N. A].pha Ave.. Grand Island. N�. 688Q3
<br />9Ba. p6�ISTRAR5816NATURE ' 29b. O�TE FILED BY qEGISTRAR IMa, Day. Yr,)
<br />,� I JAN 31 2007
<br />HHS-61 11 /03 (55tlb1 �
<br />
|