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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF H�AtTH q�1IQ HtJMA'f1F; SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE GOP}' OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA;'f�E,PA .,�I�N,T'OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECO,RDS OFFICE, WHICH IS THE LEGAL DEPOSTfORY FOR VITA�. 3���RD�,���� ',
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<br />D�ATE OF ISSUANCE �I ' �*'� --
<br />� ST�Y11l��' S COOPER�� " ��� �� �
<br />o8��4r2oo9 2 U 11 U 3 4 7 5 AS57,S.T�GlN ��-� �EGr�T�►R�y; r�
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<br />LINCOLN, NEBRASKA HUM<t�56 S,�RVICES `v , �
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES,. 4 •�,; �v� r y � r�" ''� y^..� 09 01735
<br />CERTIFICATE OF DEATFI ?'; -' � " - �� ` ' °
<br />1. DECEDENTS•NAME (Ftrst, Mlddle, Last�', SuRi�c) 2. SEX � �,�QATE OF DEATH (Mo., Day, Yr.)
<br />Arthur Frank Trieschman Male August 5; 2009
<br />4J CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo, Day, Yr.)
<br />l�'�•I MOS. DAYS HOURS MINS.
<br />CincinnaU, Ohio 88 January 3, 1929
<br />T, SOCIAL SECURITY NUMBER i 8a. PLACE OF DEATH
<br />301-07-5426 .5 L P1T ❑ Inpadent OTHER � Nursing Home/LTC � Hospice Facllky
<br />81�. FACILITf•NAME (N not irisUtuUon, gNe street and number) ❑ ER/Outpatierrt ❑ Decedent's Home
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<br />° Grand Istand Veterans Home ❑ ooa ❑ otn.r �s���ry�
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<br />81b. CITY OR TOWPI OF DEATH (fncWde Zlp Code) Sd. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� . RESIDENCE-STATE 9b. COUNTY 8c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />LL 8�. STREET ANO PIUNIBER 8e. APT. NO. 8f. ZIP CODE 9g. INSIDE CITY LIMITS
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<br />1� 310 S. Plum St 68801 � YES ❑ ao
<br />'° 10a. MARRAL STATUS AT TIME OF DEATH � Marrled ❑ Never Marrled 10b. NAME OF SPOUSE (First, Middle, Last, Sufflx� B wffe, give malden name
<br />� '� Q Marrled, but separated ❑ VMdowed ❑ qNorced ❑ Unknown Elaine Dietrich
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<br />1'�. FATHER'S•NAME (Firat, Middle, Last, SuffUc) 12. MOTHER'S-NAME (First, Middle, Matden Sumame)
<br />m Arthur P Trieschman Sr Alma Buckman
<br />� 13. EYER IN US. Al2MED FORCES? Glve dates of service if Yes. 14a. iNFORMANT•NAME 74b. REtATIONSMP TO DECEDENT
<br />$ i�ves, No, or unk.� Yes OS/26/1942 Elaine Trieschman Spouse
<br />� 1�. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />F I� aurta� ❑ DonaUon Not Embalmed August 6, 2009
<br />! Crematlon ❑ EMom6meM 76d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />F] Remorai ❑ oere� lspecrcy� G�nd island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAfLING ADDRESS (Street, City or Town, State) 17b. Zip Code
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 68801
<br />CAUSE OF DEATN See instruat ons and exam les
<br />18��PART I. ErRer the chaln of everrte� �tllaeasea, inJurles, or oompiicatlonsdhat directiy ceused the death. 00 NOT eMer terminal eveMe sucfi as cerdiac arteet, � � APpROXIMATE INTERVAL
<br />"�esplretory arteat, or veMriwlar 86�itlatlon wfthout shot�ring the eNology. DO NOT ABBREVIATE. EMer only one cause on a Ilne. Add addfdonat Ibres N neceeeery.
<br />IMMEpIATE CAUSE: ' ; onset to death
<br />IMMEDIATECAUSE�Flnal a)Hepatic�And P4lmonary Metastatic Disease, Unknown Prlmary 6 2 Weeks
<br />A ee or cOn<!�UUn �+[tln4 . . . . . . �
<br />�"��� DUE TO, OR AS A CONSEQUENCE OF: 7 onset to death
<br />Sequen8ally Ilat conditlo�s, H b)
<br />any, leading to the muse Iiated
<br />oq ttne a DUE TO, OR AS A CONSEQUENCE OF; �, oreet to death
<br />�tetthe UNDERLYING CAUSE C� ,
<br />(dlsea8e oi tnjury that tn{t{ated
<br />thj evems resulene In death) pUE TO, OR AS A CQN3EQUENCE OF: .! onset to death
<br />IAqST d� i
<br />18„PART II.OTHER SIGNIFICANT CONDRIONS-CondtUorre contrlbutlrtg to the death but rrot resutting In the undedying cause gNen ln PART L 19. WAS MEOICAL EXAMlNER
<br />Congestive Heart Feilure OR CORpNER CONTACTED?
<br />❑ YES � NO
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<br />W 20.','IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION 1NJURY 21c. WAS AM AUTOPSY PERFORMED?
<br />� ' NM pre8nairt wkhln Past Year � IVatural � Homlcltla � DrlvedOPerator � YES � NO
<br />� i! Pregnairt at dme of tleath � � � Passenger
<br />AccldeM Pentling Inveatl8adon
<br />„ Na Pregnam, but pree���� ��f d� � pede�t� 21d. WERE AUTOPSY FINDWGS AVAILABLE
<br />� � 6ulclde �] Cou�d not be determ�ned TO COMPLETE CAUSE OF DEATHI
<br />Not preB�aM, but preBnaM 49 days to 1 year beiore death �] Other (Specty)
<br />� [] Unknown fi pregngirt wlthtn Ure paet year � ❑ YES ❑ NO
<br />� 22�. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURKAt home, fartn, street, faatory, of(ICe bullding, construcUon slte, etc. (SpecHy)
<br />$
<br />S 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY qCCURRED
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<br />❑ YES ❑ NO
<br />22f: LOCATION OF INJURY e STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CQDE
<br />� � "- 2?a:QATEOFI;EATN;t�b.;9ay:'F*.?--- - -- -- ._;� .__ , �- ?.4a.DATE3IGNED-4Mn.•-AaY.Yr.y__� 29b nM.�_O_n�eSH_ »
<br />� August 5, 2009 .� � �
<br />��� 23b. DATE SIGNED (Mo, Day, Yr.) ?3c. TIME OF DEATH ���� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />E� z Au ust 6, 2009 ; 05:00 PM � o
<br />$ 0 3tl. Ta tha best of my knowledge, death oceurted Qt the Hme, tlale and plaee 8 W� 24e. On the basls ot examhiatlon'and7or imealigaticn, In my optnlon deeth oeeurted at
<br />�� and due to the cause(s) atated. (Slgnature and!Tltte) � z p the tl�rre, date and ptace antl due W the cause�s) ata�d. (SlBnature and Tftle)
<br />~ Jennifer King, MD F g s
<br />25. DtD TOBACCO USE CONTRIBUTE TO THE DEAT ? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WRS CONSENT GRANTED?
<br />I❑ YES ❑ NO ❑ PROBABLY � UNKNOWN ❑ YES � NO Not Appllcabla H 26a Is NO ❑ YES ❑ NO
<br />2. E, TLE AD RE O CERTI IER (PHY C , R ER I O A RNEl7 ype or Print
<br />Jennifer King, MD, 2300 West Capital Avenue, Grand Island, Nebraska, 68803
<br />28a� REGISTRAR'S SIGNATURE � 28b. DATE FlLED BY REGISTRQR (Mo., Day, Yr.)
<br />�` August 10, 2Q09
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