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STATE OF NEBRASKA �, � '; . ; ,
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH<gl�lD°�Y�'TAi1( SERVTCES, IT`CERTIFIES
<br />THE BELOW TD BE A TRUE COPY OF THE ORIGIAIAL RECORD ON FILE WITH THE NEBRASII.�,�F�(�LCI��MF11J'�'�(3� hfEALTt1 AND
<br />I HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL""RE�ORD$ .� �, � g
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<br />DATE OF ISSUANCE /,�, • , �,
<br />04/20/2011 �T�a�" � COOPER � � t ,, �"
<br />2 O 11 O 3 9 5 8 �s���ra�r p �r�r� �;
<br />CjEP.��TM�'IS�IT`dF'�H�A�L°�H'AN� �,'
<br />LlNCOLN, IVEBRASKA M�IM�N .S�RVIG�S,_ : ' `
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER�/,lCE�,�'� �� � a Y ��^i �� H,� +��, � � O� 269
<br />CERTIFICATE OF DEATH ' 1 , �
<br />1. ECEDENTS-NAME (First, Middle, Last, Suffitt) 2. SIX � ".�DATE OF DEATH (Mo., Day, Yr.)
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<br />�lerbert Wllllam Heusel Male � ° April 18, 2011
<br />4. C,ITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY B. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs•) MOS. DAYS HOURS MIN3.
<br />enri+n Nebraska 82 June 12, 1928
<br />SECURPIY NUMBER
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<br />�d Island Veterans Home
<br />OR TOWN OF DEATH pnclude Zlp Code)
<br />�d Island 68803
<br />arM number)
<br />8a. PLACE OF DEATH
<br />OSH PRAL � InpaUent OTHE � Nursing Home/LTC � Hospice Faeliity
<br />� EWOutpatleM ❑ DecedeM's Home
<br />� DOA ❑ Other (SPecffY1
<br />Bd. COUNTY OF DEATH
<br />Hatl
<br />a. RESIDENCESTATE 8b. COUNTY 8c. CITY OR TOWN
<br />� ebraska HaII Grand Island
<br />d: STREET AND NUMBER 8e. APT. NO. 8f. ZIP CODE eg. INSIDE CITY LIMIT9
<br />24 Andrew Ave 68801 � res ❑ No
<br />08. MARITAL STATUS ATTIME OF DEATH � Mlarrt�l ❑ Never N�rtiad 10b. NAME OF SPOUSE {Firat, Middle, Last, Suffix) ITwffe, give rtniden name
<br />�] Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown LOPa B@thB118 Paul
<br />1.IFATHER'S•NAME (First, Middle, Lasf, Suftix) 12. MOTHER'S•NAME (First, Middle, Malden Surtmme)
<br />Herbert Heusel Anna Muhlberger
<br />3.I� EVER IN U.3. ARMED FORCES7 Gfve datea of service lf Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />es, No, or un�c.) Yes 12/13/1951-12/05/1953 Lora Bethene Heusel Wife
<br />5.' METHOD OF DISPOSITION 18a. EMBALMERSI(iNATURE 18b. LICENSE NO. 18c. DATE (Mo„ Day, Yr.)
<br />� euna� ❑ oo�non Matthew T. Myers 1411 April 21, 2011
<br />� CremaUon Q Entombmertt 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />j Re�o�ai ❑ o�n�►(s�e�ry� Central Nebraska Cremation Services Gibbon Nebraska
<br />7a. FUNERAL HOME NAME AND A1NLIN� ADDRE3S (Street, Cily or Town, State) 17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />uls�ae orcomlWOn resuiting
<br />�" �� DL
<br />Se4uendal�Y nat eomlitlone. It b)
<br />al,�y. Ieading to the cause Ileted
<br />on nne a p�
<br />Etrterthe UNDERI.YINO CAUSE C �
<br />(disease or InJury that InlUated
<br />the eveiqe resultl� in death) Dl
<br />� d)
<br />& PART 4 FrMaz the chaln af eveMa��di�as�, InJudee. w eomplleallonsdhat direGlY �aused the death. DO NOT errter temdnal evente such ae cardlae arreat, � APPROXIMATE
<br />, respUatory arresy or veritrliwlar flbrplatlon wltliout showing the edotogy. DO NOT ABBREVIATE Frrter onty o�re cauee on a Ihre. Add addidonal tl�rea H neceaeary. �
<br />IMAAEDIATE CAUSE: � o�et to death
<br />,m�e�a� �us� �„e, a) Vascular/Alzheimers Dementla ;> 1 Year
<br />OF:
<br />OF:
<br />TO, OR AS A CONSEQUENCE OF:
<br />�. PART II.OTHER SIGNIFlCANT CONDIT70NS�GOmIn
<br />Coronary Artery Disease; Atrial Flbrillatlon.
<br />1. IF FEMAF.E:
<br />� Not pregnaM wkhln past year
<br />PregnaM et tlme ot death
<br />Not W88��4 but P�B�t within 47 daYe ot tieaN
<br />p NM preg�mnt, but pregnaM 49 days to 1 year befoie tleatb
<br />p Unlmown H pregnaM w@hln the Past Year
<br />. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME
<br />o�et to death
<br />onset to
<br />o11Set t0
<br />coMributl� to the death but not resulU� In the urrclerlying cause ghen In PART i. 78. WAS MEDICAL EXAANNER
<br />ORCORONERCONTACTED?
<br />❑ v�s � No
<br />21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED7
<br />� ruw� ❑ Ho�u�taa ❑ umenona�sa. p ves � No
<br />� Acddeirt � Pendln8lnveatl8adon ❑ Pessan9e�
<br />� BWcltle � CoWd not be detarmined ���7e� z�d O OMPLETE CAUSE OF DEATH?
<br />� � other (SP��v)
<br />OF INJURY I 22c. PLACE OF INJURY At home, Tarm,
<br />�d. INJURY AT WORK? I22e. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO
<br />3L LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYITOWN
<br />23e. GATE OF DEATH (Mo., Day, Yr.)
<br />� � April 18, 2011
<br />} 23b. DATB SIGNED (Mo, Day, Yr.) 23c. TIME OF DEATH
<br />I Z A ril 18, 2011 12:43 AM
<br />� � 0 Ta the beat oT my Imowi�IBe. death xwrtetl at the tlme, date and ptace
<br />II � atM due to tlre cauael8) atated. IS19nah+te and TWe)
<br />JenNfer King, MD
<br />YES IXI NO
<br />UNKNOWN I fIYES
<br />Jennifer King, MD, 2300 West Capital Avenue, Grand
<br />. REGISTRAR'S SIONATURE A'i >I .' '' IR
<br />❑ YES ❑ NO
<br />factory, oftice bWdi�, co�tructlon atte, etc. (Spectfy)
<br />STATE
<br />ZIP CODE
<br />$�� 24a. DATE SIGNED (Mo Day, Yr.) 24b. TIME OF DFATH
<br />� � Q � 24c. PRONOUNCED DEAD (Mo„ DaY, Y�.) 24d. TIME PRONOUNCED DEAD
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<br />$� 24e. On the basls of e�mminatlon endlor InvestlBatlun, In my opinlon death occuned at
<br />the tMe. dateand place and due-to tdec.wse(s) ffiated. (Stgt�aLue.and-71tte1 �
<br />F $ �
<br />0
<br />� NO
<br />' T, C N P
<br />Nebraska, 68803
<br />Not Appllcable IT 28a ta NO ❑ YES U NO
<br />28b. DATE FlLED BY REGISTRAR (Mo„ Day,
<br />April 19, 2011
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