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STATE OF NEBRASKA
<br />, WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTkI ANi
<br />° � THE BELOW TD BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA !�
<br />HUMAN SERVICES, VITAL RECORDS OFFlCE, WHICH IS THE LEGAL DEPOSITORY FOR. VIT�L �F
<br />DATE OF ISSUANCE � �
<br />ST��Y'S',C
<br />JUN 1 0 200� � as�r�an��`�
<br />2 0110 4�5 9 � D�PA�T.M�111e�
<br />- 11NCOLN, NEBRASKA H(f1�1,4FV $ER�'
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<br />S�RVIC�S, IT CERTIFIES
<br />�QF� HF.4LTH AND
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<br />� STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPO ��� "�
<br />CERTIFICATE OF DEATH ' '� U g� °' � � ��� ' ��, .
<br />'�'�` t. DECEDENT'S-NAME (f(rat, Middle, Last, 5utfix) 2. SEX 3.DATEDFDEi�TW (�Ao.,Day,Y�.j
<br />Male Ma 28 2009
<br />r�'�' 4. CITYAND 3TATE ORTERRITORY, OR FOREI�N COUNTRY OF BIRTH 5a. A�E-Lest Birthdey 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day,Yc)
<br />� (Yrs.) MOS. DAYS HOUflS MINS.
<br />;'�`�'��� St. Pa.ul Nebraska � 61 � March 19, 1948
<br />7. SOCW.BECURITY NUAffiER Be. PLACE OF DEJiTH
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<br />��'."?�:=?p 507-5(-�4�]4 - - . HOSPITAL: ]� Inpatient Q� 0 NureingNome/LTC �❑HoapiceFecfiiry
<br />` 86. FACILITY-NAME (If not Inatftutlon, gfve etreet and number)
<br />I ', �':. ^. �'�; O. ER/Outpatfent ❑ Decedeirt's Homa
<br />�� ❑ D64 ❑ Other(3P��H)
<br />� St. F'raT1C1.S M2C�1C31. CP11tP.r'
<br />yry _� Bc. CITY OR TOWN OF DEATH (Inciude Zip Code) 8d. COUNTY OF DEATH
<br />��� � Grarid Island b8803 � Hall �
<br />� 9aRESIDENCE-STATE � 9b.CWNT`( � - 9aCITYORTOWN
<br />>` Nebraska Hall Grand Island
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<br />',I, 3� 9d.3TREETANDNUMBER Be. APL NO 9f. ZIP CODE Bg.INSIDE CITY LIMITS
<br />�;y < 1820 rin Road 68801 � YE9 ❑ n,o
<br />��~ 10a. MAAITAL STATUS ATTIME OF DEATH � MarBed ❑ Never Married tOb. NAME OF SPOUSE (Ffrat, M(ddle, Last, Suttix) If wlfe, give malden neme.
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<br />e ❑ MeMetl, but aepareted ❑ Widowed ❑ Divorced ❑ Unknown J�11e A. wO�P�s
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<br />� 11. FATHER'S•NAME (First, btiddle. Laef, Suttix) 12. MOTHER'S-NAME (Ffrst, Mlddle, Meiden Sumflme)
<br />Herbert Falk Hazel Ha.rve
<br />.'� 13. EVER IN U.S. ARMED FORCE8T �ive datea oi aervtce B yee. 14a. INFORMANT NAME 74b. RELATIONSHIP TO DECEDENT
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<br />��+ ea no,o���k.�03/12/68 to 12j07/69 Jane A. Falk Wife
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<br />� 76. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE� 186. LICEN3E N0. 18c. DATE jMo., Dey, Yr. )
<br />�"` Xls�n� ❑o�ro� a g�,� rrt 1078 June 1� 2009
<br />3 � ' ❑Cremallon. ❑Entombment i6d.CEMETERY,CREMATORYOROTHERLOCATION CITYlTOWN BTATE
<br />�`,'��(n` ❑ Removel ❑ Olher (Specity) $].IRWOOCZ '�2't@L'Y S't. P'dlll. � N?��'dS�{c1
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<br />��-y 77a FUNERAL HOME NAME AND MAILING AODRE33 (Straet, CIry orTown, Statej - � 17b. Zip Code
<br />�';` Peters Funeral Hane, Inc. P.O. Aox 181 St. Paul, NE 68873
<br />��, "��,' �k�y .�, ��:�` "' h..� �ira �,6,y��t.�nr � *`�? �, ,a �<s; t�'� .�. �_� �#1��� 7.,��,� � �1 ',�-'.� x�'�':� w�`�n"�„
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<br />���"�; 1& PAAI' I. Enter the cha�n of avertrs--diseesea, injuries, m comptice8ona-fhat directly ceused tha death. DO NOT eMer tarminal evenis euch as cardlec erreat, APP�p�� ���A�
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<br />_:;�„�-� respireiory arcest, or veMricuier fibrillaUon without ahowfng the etio�ogy. DO NOT ABBREVIATE. Errter only one ceusa on a Iine. Add addidonal Iines tl necesearx i�
<br />'' � ^ IMACEDIATE E: � onaettodeath
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<br />G - � I�MEWATECAUSE(Fhrel � �
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<br />�w����9 DUETO,ORASA ON3E�UENCEOF: t otreetMdeath
<br />� ,` > Indemhl I
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<br />��,. sequentl¢Ityliateonmtions,u ro� � �1,.�G V(/lJl.
<br />�� ���� DUETO,ORASACONSEDUENCEO. I onse death
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<br />�ffmurmEwxwocnuse �
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<br />._ �` (dlee�orb�jurythetin(deted �°) I
<br />��°����"�) DUE T0, OR AS A CONSE�UENCE QF: i onset W death
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<br />��, �r� ��� 78. PART II.OTHER 3I�NIFICANT CONDITIONS-Conditlu� wnMlwting W the death but not reaulUng in the rmderiying cause given in PAHT I. 18, WAS MEDICAL D(AMINER
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<br />1 `�`�� ❑ YE3 WYPIO
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<br />� '� 20.IFFEMALE: � 21a. ROFDEATH 276.IFTRANSPORTATIONINJURY.21aWASANAUTOPSYPFAFORMED?
<br />i � :,` ❑ Nolprepnentwlthinpeatyear ��I OHomlcide ❑DrlvedOperator 0 YE8 �O
<br />0 Pregnant at time ot death ❑ AccldeMO PenNng InvesUgation � P�Bar
<br />*} p � ❑ Not pregnant, but pregnanl within 42 days of deaN � P � B �� 21d WERE AUTOPSY FINDIN(iS AVAILABLE TO
<br />� �. ,�� ❑ BWcide ❑ CoWd not be detertnined 0 � �SPedfy� .
<br />� ❑'NotpregnaM,butpragnam43daysroiyearbeloredeath COMPLETECAUSEOFDEATIi?
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<br />� � � �,' O Unknownifpregnentwlthinihepastyear ❑ YES ❑ NO
<br />�i�', ��'.. �`� 22a. DATE OF INJURY (MO., Deg, Yr.) 22b. TIME OF INJURY 22c. PU+CE OF iNJURY-At home, tartn, eireet, factury, office building, wnafrucUon afte, eta (Specity)
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<br />I ��'�,d'."',���'., 22d.INJURYATWORKT 22e.DESCRIBEHOWINJURYOCCURRED �
<br />I ,�' ❑ YES ❑ NO
<br />22F. LOCA770N OF INJURY • STREET & NUMBER, APT. N0. CfTY/�OWN S�UE ZIP CODE
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<br />�` „ �t 23a.DATEOF�EATH (MO.,Day,YrJ � 24a.DATE8IGNE� (Mo.,Oay,Yc) 24b.TIMEOFDEATH �
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<br />�� 23b.DATESI�NED�(MO.,Day,Yr.) - 23c.TIMEOFDEATH - ��� 24c.PRONOUNCEDDEAD(Mo.,Day,Yr.) 24d.TIMEPRON011NCEDDEAD
<br />�.�.� � a Z ok�s►t 2 o to'.5l e► . m �` Z m
<br />:� ri�,� � 23d. T b m my kn I ge, o�urred at e time, date and lace ��� 24e. On�ihe heats of exeminaUon endlor imesNAeUon, in my opinion deaN occurr�d at
<br />"�i F �e to (s) tat d: Signatur�a tle )♦ �� � the tlma, date and place and due to the cauae(s) atated. (Signature and TIUe )♦
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<br />y �yY. 25.DIDTOBACGO S ONTRIBUTETOTHEOEATH? 28a.HASOR�ANORTISSUEDON IONBEENCON3IDERED? 28b.WASAONSENTaRANTED?
<br />+^,�;_ ❑ YES � NO O PROBABLY ❑ UNKNOWN ❑ YES � � � Not Appllcable if 2Ba le NO ❑ YE3 � NO
<br />�� 27.f�1IdE� ITLE DADqRE6S0 CERTI�ER(P YSICUIN,CORO '3 HYSip(qNOR U A RNEYj orPdnt) �
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<br />� 28aREa18TRAR'8Si(3NAANRE � 28b.DATEFILEDBYREQISTRAR (Ma,Day,YrJ
<br />,(�. JUN � 2009
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<br />HHS-81 11/03 (55D61)
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