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WF�N TF�S COPY CARl�ES THE RA13ED SEAL OF THE NE6RASKA HEALTH J
<br />SYSTEIY� IT CERT�S TFIE BELOW TO BE A TRUE COPY OF THE OR/GINAL�1
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI�T7
<br />THE LEQAL DEPOSITORY FOR VITAL RECORDS �
<br />. /� -�
<br />DATE OF ISSUANCE
<br />JUN 17 1997
<br />� __ UNCOLN�NEBRASKA
<br />2 0110113 7 '�"�
<br />Assi�;^q
<br />HEALTH AND Hf�4
<br />STATE OF NEBRASKA - DEPARTMENT OF I
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />I 1. DECEDENT - NAME � FIBST
<br />�''-"; �� -�, � t �
<br />AN�EY�'Z4S�F�; �,
<br />��� ���� : 7 � ; s {
<br />�-= -_ ;,, ,' s ._
<br />t,.-�� -
<br />MIDOLE lA3T 2. SEX 3. DATE OF DEATH� /Month, Osy, Year/
<br />Gustave Lambrecht Male June 5 1997
<br />+ 4. CITY ANO STATE OF BIflTN - l!/ not b� U.S.A., neme camtry/ 6a. AGE - leat &rtMey UNOEfl 7 VEAfl UNDEfl 1 DAV 8. DATE OF BIRTH /Month, Osy. Yeer/
<br />(Vn.) 6b. MOS. DAVS 6c. HOUHS MINS.
<br />, Prosser Nebraska 57 +_. ' ' November 13 1939
<br />-- _.. - -----�-
<br />� 7. SOCIAL SECUflITY�NUMBER 8a, pLp�.: UF CU�.
<br />■� (�
<br />� SOS'52��37 / HOS%TAL: ��� OTHER: � NwNnp Home
<br />� Bb. FACILITY - Name OJ m+ MsNtuOOn, y/ve sbeet eiM nwMer/ � ER OutpaUent � Re�idenea
<br />� 1 3244 W. Schim Dr. ❑�A � a„�,�„�, Fesd lot - farm
<br />Bc. CITY. TOVMI OR LOGITION OF DEATH Bd. INSIDE QTV LtlNITS � 8e. COUNTY OF OEATH . � �
<br />Wood River Y„ ❑ No � Hall
<br />Ba. RE3IDENCE - STATE 9b. COUN7V Bc. q7Y, TOWN dR LOCATION Bd. STAEET AND NUMBER fbu.ri�dng Z/p Cotle/ Be. MISIDE CITV UMITS
<br />Nebraska Hall Wood River 13244 W. Schimmer Dr. 68883 ��. ❑ No �
<br />10.MCE - ls.q.. White. Biadc. American Indian, i t. ANCESTRYI•.o.. heYan, M.dnn, Owmsn �te.l \ 12.� MARH�ED � WIDO WED 13. NAME OF SPOUSE /H wl/a �ve maMen neine!
<br />e �� Y) �� NEVER OIVORCED
<br />White Germ ❑ ❑ Chazlann Botts
<br />16a.USUAL OCCUPATION -/Glve kind o7 work drne du�/ng most 14b. KIND OF BUSINESS INDUSTRV � 15. EDUCATION FY ONLV HqNEST URAOE COMPLETE01
<br />�7 or wo.king u�e, e�an u.eNredl a� _--� � o` a.m.mw « s.00�ew lo-� 21 ca�a n.a o� s� �
<br />�� 18. FATHER - NAME FIHST MIDDIE LAST
<br />a Arthur La�
<br />78. WAS OECEASED EVEN IN U.S. AflMEO FORCESl
<br />._ IVn, no a uNC.) � IM Ysa. oiv. wer snd da2.. a ewviea.l
<br />12 �
<br />17. MOTHER FIfiST MIDOLE MAIDEN SURNAME
<br />19a. MIfOHMANT - NAME
<br />19b. INFOflMANT MAILNJG ADDRESS - 1STREET Ofl R.F.D. NO., CITY OR TONRJ, STA1E, ZI%
<br />13244 W. Schimmer Dr. Wood River ;�i�;. 68883
<br />20. EMBAUAER - SIGNAiUAE LICENSE NO. 21a. METHOD OF OISPO:>I IION 27 b. DAIE 21c. CEMETERV OR CflEMATOflY - NAME
<br />C ��� ��,��, ❑ R ,,;, o ��, 06/09/ 1997 Wood River Cemeter
<br />22a. F E HOME - NAME . 21d. CEMETERY OH CflEMATORV LOCATION QTY ON TOWN
<br />A fel Funeral Home ❑ a«^��^ �����^ Wood River Nebraska
<br />22b. FUNERAL HOME ADDRESS (STflEET Op p.F.D. NO., CITV OH TO WN, STATE, ZIP) � .
<br />Wood River NE. b8883-126
<br />STATE
<br />� 23. IMMEDIA7E CAUSE IENTER ONLY ONE CAUSE PER LINE FON lal, Ibl, ANO (c11 Intavd between oroet and UeatA
<br />.� PART accidental suffocation �3-5 minutes
<br />�7 (el �
<br />� DUE TO ON AS A CONSfQUENCf OF � � Irnervd between oroet aM Aeath
<br />�, lack of oxygen and presence of inethane gas �
<br />� DUE TO UR AS A CONSEQUENCE OF ' � I Imnvd between orott aml dea[A
<br />I I
<br />OTHEP SIGNIPICANT CONDITIONS - Condtbm connbminp �o tM Mnn 6m no� rNnW PAR7 III IF FEMALE WAS iHEflE A 2a. AUTOPSY •• 25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCV IN ?HE PAST 3 MONTHS?
<br />�� EXAMINEH ON CORONER7
<br />� (Apu 70-54) Yw No Ves No Yes No
<br />2�� 28b. DATE OF INJUflY IMO, by, Y.I 28c. HOUN OF MIJURY 2Bd. OESCNIBE HO W INJURV OCCUNREO u n e r q r o u n
<br />�A�M ❑U�.,,.,,�,,., June 5, 1997 6.�Op ccidental suffocation - well
<br />❑ 5uicie. ❑ penai�p 28e. INJURY AT WORK 28f. PIACE OF INJUflV - At han�, frm. Kr�. �ac�ory 2Bg. LOCATION STREET OR R.F.O. NO. CITY Ofl i0 WN STATE
<br />�❑ farm���g� �d 13244 NJ Schimmer Rd I��ood River NE
<br />❑ HaniWds Ime�tipmion Vef No
<br />27a. DATE OF DEATH lMo, Day, Y./ � 2E�e. DATE SIGNED IMo, Dsy, Yr.l 286. TIME OF DEATH
<br />_ JuneS 1997 ��= une 11, 1997 p 6:30 n
<br />_ �
<br />�� a 27b. OATE SiGNED (Mo, Oey, Y�.J 27c. T{ME OF DEASH �� g� 28c. PFIONOIRJCED DEAD /MO, Dey, Yr./ 2Bd, PRONOUNCED DEAD lHOUr/
<br />�o P M "�� une 5, 1�9� 7:15 p
<br />_� x
<br />'�� 27d. To the 6est of my knovAedqe, deeth occurred et the time,dete and pince end dua to the � f a 2Be. On the baaia ot a on a�/ v �'o , pirion d occuned,a[
<br />° causeafsl nataa. the time. Uata a ue 1. et � 1'U
<br />ISlgnaturs an� iltle) ► � (Signatwe aM Titlel � /
<br />. 29. DID TOBACCO USE CONTRIBUTE TO THE DEATHi 30a. HAS OflGAN Ofl TISSUE DONATION BEEN CONSIDEHED7 30b. WAS CONSENT TEDT
<br />� VES �I NO � UNKNOWN � YES � NO VES � NO
<br />31. NAME AND AODRESS OF CENTIFIER 1PHVSICIAN, CONONER'S PHVSICIAN OR COUNTY ATTORNEY) ?YM w H/nU
<br />Michelle J Oldham, DHCA 117 lst St. Grand Island f�E 68801
<br />32e. REGISTMR 32b. DATE FII.ED BV REGISTRAfl /MO, Dsy YrJ
<br />� �.�/.r -�- - JUN 16 1997
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