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<br />� O�.1 O 16 5� STATE OF NEBRASKA
<br />WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEt�[
<br />• SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORlG��
<br />'THE NEBRASKA HEALTH AND HUMAN SERVlCES SYSTEM, VITAL STATI
<br />THE LEGAG DEPOS(TORY FOR VITAL RECORDS._ .
<br />DATE OF lSSUANCE Y ` r j� �
<br />DEC 13 2006 �� R� l7 ��/1 � A �
<br />LMCOLN, NEBRASKA H�
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVI
<br />CERTIFICATE OF DEATH
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<br />I.OECEDENT'S-NAME (First, Middle, Last, Suffix) 2SEX -� 3.DATEpFDEATH{'Mo.,Day,Yr.)
<br />Haroid Herman Niemoth
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand island, Nebraska
<br />7. SOCIAL SECURITY NUbSBER
<br />508-46-7048
<br />8�. FACILITY-NAME (If not instliutlon, give street and number)
<br />Tiffiany Square Care Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8a. RESIDENCESTATE 9b. COUNTY
<br />Nebraska Hall
<br />9d.STREETANDNUMBER
<br />1613 Spruce St.
<br />t0a. MARITAL STATUS A7 TtME OF DEATH �O Married ❑ Never Memed
<br />❑ Maraed, 6ul eeqarated O Widowed ❑ D�vorced 0 Unknown
<br />Male �November 5, 2006
<br />Sa.AGE•LastBirlhday Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day,Yr,)
<br />(Yrs.) MOS. DAYS HOURS MINS.
<br />' gp January 17, 1926
<br />Ba. PLACE OF DEATH
<br />HOSPITAL; Q Inpatlenf OTHER � NursingHome/LTC ❑HosqceFacitlty
<br />❑ ER/Ouq�allent ❑ DecedenPS Hane
<br />❑ ooa ❑ omerlSPedN1
<br />8t1. COUNP.' OF DEATH
<br />ea ctN oR Towro
<br />Grand Island
<br />9e. APT. NO 9t. ZIP CoDE Bg.INSIDECITY LIMITS
<br />68801 fa� ves ❑ NO
<br />NAME OF SPOUSE tFlrsL Middle, Last, Sullix) II wite, give malden name.
<br />Rosella N
<br />11. FATNER'S•NAME (Ftrst, Mlddle, Last, suflix)
<br />Jose h Niemoth
<br />13. EVER IN U.S, ARMED FORCES? Give datea of service ityes. 14a.INFORMANT•NAME
<br />(Yes, no, or unk,� No Rosella Niemoth
<br />15. METH00 �F DISPOSITIQN 1`EMBALM = ON RE �
<br />� 8udal ❑ Donatton � ��
<br />❑Crematlon ❑Entombment 16d.CEMETERY,CREMATORYOROTH OCATI01
<br />❑Removal ❑Other(Spec�ly)
<br />Westlawn Memoriai Park Cemetery
<br />17a. FUNERAL HOME NAME AND MAIUNp ADDRESS (Slreet Clry orTown, State
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, �ebraska
<br />12. MOTHEfl'S•NAME (firat,
<br />Minnie Gosda
<br />16b. LICENSE NO.
<br />1c� `7 /
<br />ciTV i rowN
<br />Grand Island
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<br />Mlddle, Maiden Sumame) '
<br />14b. RELA710NSHIP TO DECEDEN7
<br />Wife
<br />18c. DATE (Mo., Day,Yr. )
<br />November 8, 2006
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />- C/lU�E OF DEPTH (Se•, Instructions ana examoies�
<br />I8. PART l. Enler the chaln ot events-•dlseases, InJudes, or compNcaBoS�s--tha! tlV.aetty caused ttie deaUh, DO NOT enter temilnal ev�nls such ea cardlacarreat, � APPROXIMATE fNTEflVAI
<br />I
<br />respitatory artesl, orventricular IfbdllaAon withoul ahowing the eUology. DO NOT ABBAEVIATE, Enteronly one cauae on a Ilne, Add add111onal0nee ll necessary. �
<br />IMMEDIATECAUSE, � oneettodealh
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<br />IMMEDWTECAUSE(F„al (a � (� ��.0 Cl�O M/? ,f�,� �� �0 � � ��
<br />dbeeseacondltbnr�wRlny DUETO,ORASACONSEQUENCEOF: � I oneetlodeaM
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<br />i onsettodealh
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<br />� ,onsetto dealh
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<br />18. PART II.OTHER SI�NIFICANT CONDITIONS•Conditlons contdbutlng to the death but not resulUng In the underlying cause grven m PART I. 19. WAS btEDIGAIEXAMINER
<br />h deetl�)
<br />Sequs�tleltyliatcondltlona,8 (
<br />any, Iesdiny to th� ceusa Nsted DUE T0, OR AS A CONSEQUENCE OF:
<br />on Iirn a.
<br />EntalheUNDEHLYNQCAU9E � '
<br />(dNeeseorinJurylhatMlGated �°)
<br />theevenbnsultinghdeari) DUETO,ORASACONSEQUENCEOF:
<br />�
<br />{ l� O�er (Spediy) I ppMPLETE CAUSE OF DEA7H?
<br />I ❑ YES ❑ NO
<br />22c, PLACE OF INJURY-Athome, tarm, street, lactory, oflfce Duiltltng, const�uctlon atle, eta (Specfry)
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY • STREETB NUMBER,APT. N0. CITY/iOWN
<br />Ofl COflONER CONTACTED�
<br />❑ YES ❑ NO
<br />21a.MANNEROFDEATH 27b.IFTRANSPORTATIONINJURY 21aWASANAUTOPSYPERFORMED?
<br />�Natutal ❑ Homlcide ❑ DdvedOperetor
<br />❑ Passenger 0 YES �10
<br />Q Ac^�der�6� . ;... _ .. . . . .
<br />I ❑Petlesldan z�d,yyEREAUTOPSYFiNDINtiSAYAIUI6LET0
<br />��SWddtr � Ftnuldr3nt bn detemnit+ad _. t _ . - - . � . . . __ . .. _ . . . _ _. _. _
<br />� j eea. UAit OF INJUNY (Mo„ qay, Yr,) 21b. TtME OF INJUR'f
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<br />� 22d.INJURYATWORK? 22es DESCRIBE HOW INJURY OCCURRED
<br />W 20. IF FEMALE:
<br />LL ❑ Notpregnantwithlnpastyear
<br />� ❑ Przgnar�t a: Gme uf 3eai��
<br />� (7 Notplepnanl,bytpregnantwfthin42daysotdealh
<br />$ O Not prepnani, but pregnant 43 days to 1 yearbelore dea�h
<br />m
<br />E ❑ Unknownilpregnantwithinthepastyear
<br />STATE
<br />• e
<br />� t ��
<br />ZIp CODE
<br />23a.DATEOFDEATH (Mo.,Day,Yr.) �, 24a.DATESIONED (Mo.,Day,Yr.J 24b.TIMEOFDEATH
<br />�� November 5, 2006 � ` ��¢ m
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<br />ffi}� 23b. DATE SI6NED (Mo., Day,Y�.) 23aTIME OFDEATH �_�� 24c,AHONOUNCEDDEAD (Mo., Dap,Yt.) 24d.TIMEPRONOUNCEDDEAD
<br />na � G 5:05 P.m ��`Z ►n
<br />$°� 23d. To the best o knowledge, 8eam occurr the tlme, date and piace � w z� 24e. On C�e basla ol examinatlon and/orinveatlgatlon, In my opinlon dealh occurred at
<br />F� and due t e use(sClat .(Slgna� p d TIHe ) 7 0¢� Ihe lime, date and place and due to Ihe cause(s) stated. (S�gnaturo and Tltle )♦
<br />� L� uA� �.�� ~ c o i `
<br />25.DlDTOBACCOUSECaNTflIBUTETOTHEDEATH'� ' - Z(w.FiRSOn3Aiv°;�i;�s��nHh��ONBEENCONSIDERED? 26b.WASCONSENTORANTEDT
<br />___.
<br />YES ❑ NO ❑ PROBABIY ❑ UNKNOWN ❑ YES 0 Not AppliCable 1126a le NO ❑ YES 0 -
<br />27. AME,TITLEANDADDRESSOFGERTIFIER (PHYSIqAN,CORONER'SPHYSICIANORCOUNTYATTORNEY) (rypeorPnnq
<br />David Colan, M.D., 729 N. Custer Av and Island NE 68803
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