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2 p�. i Q 5 0 6 4 STATE OF NEBRA3KA�
<br />Orval Edmund Hjorth
<br />4. CRY AND STATE OR THRRI70RY.OR FORQ6N tAUNTRY OF B1RTH
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<br />Wisner, fVebraska
<br />z socw� sECUam nweneen
<br />OF HEAL7H AND HUMAN SEitVICES �� °����
<br />nF nFaTN .
<br />Male May 17, 2011
<br />6a AG&tast BMhday 6b. UNDER 1 YEAR Ba UNDER 1 DAY & DATE OF B1RTH IGAo.. Day, Yr.)
<br />�Yre.) WO& DAYS HOU� MMS.
<br />7g January 18, 1932
<br />ee. P�ace oR oEnrr+
<br />� 507-28-0823 H65RITAl: QX InpeUeM °TM�a: O n�ms Aemen.rc ❑ Hespice Feetlity
<br />V 86.FACIL�SY=AfAME l9nottr�t}WNrn.9hreaVeatandnumbary ❑ ERrOutpatte�N ❑Deeetla�sNome ..
<br />n ' �/Q �2L�IC8� �i@TItBi ❑ OOA ❑OWer(S�att7tl
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<br />� 8c. CiTY OR TOWN GF DEATH (bm3nde ap Cm1e) 8d C4UNTY OF DEATH
<br />W Omeha 68105 Douglas
<br />� 9a RE910ENCESCATE � 8b. COUNTY 8a CITY CR TOWN
<br />� Nebraska Hall Doniphan
<br />� 9d S7R8E'f AND N11ES8ER Be. APT. NO. BL 2IP CODB 9g.. tNS�DE C1tY IQNITS
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<br />� 3�6 Pine St. 68 � � r � ❑"°
<br />� 108. MARITAL BTATUB AT TI67B OF DEATH � ACarttad ❑ Naver 6Amried 70b. NAME OF SPWSE (Fhst, ACiddla, Laet, Sufl6c) it wHe, gWe matden nama.
<br />� �nn°"�°°'w°a°y�r�° 0"na°'� ��°i``°"a'' �°"r°'°'"" Mavis June Nebola
<br />E 91. FATHER'8-NAAAE (�7re1. AEiddle, Les4 8uftirzl '12 �OTHER'8-NA�AE IFlBt, Middle. Malden Sumemel
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<br />�' Harold H'orth Cathedne Pojar
<br />N� 13. EVER W U.& ARMED FORCE39 GWe datea oT aerviee N Yea 14a 1NFORMANT-NAME 14h. RELATlONBH(P TO 6ECEDENT
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<br />�" Ivsa roo. o* um�.) Yes 05l27/1952-05/26/19 Hope Lienemas�n Daughter
<br />1b. METHOD OR b18PO8iT[ON aea. ennsni.ne �eb. uc�use Ho. �s�. oa� mm. nex r� y
<br />�� Cl����* 3'� May 23, 2U11
<br />pc„man'^ penmmnm�� sra�
<br />aR �� ❑��� 18f1. CEIBIETERY, CREMA7 OR OTHER LOCATION CiTyl7'01NN
<br />Cedarview Cemetery Doniphan
<br />17a FUNERAL HOAAE NAME ANO MAIUNG APORE53l8treet, CHy orTwvn, Statal
<br />AA Faiths Funerat Home, 2928 S. Locust Street, Grand Island, NeBraska _
<br />I�ebraska
<br />t�u. ztpcnee
<br />I �8801
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<br />� reaphatoryerteat.mventriwlarliertllaeenw�theutedowiasenaeBO�eB9.aoNOSa88REV�n7e.6imroalvmreemmeonetOm.addadaBienalMeeu�re�p. �
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<br />10AMEOWTE CAUSE: � onset to death
<br />UIdM11E0IATE CAUSE (FMa1 '
<br />� � .�°-�'�T�e �31r��.G� ,�. ; ,e.�
<br />ms� m�w�. e '
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<br />OUBTO, OAA9 A CONSEGUENCE OF: '°�et to deefli
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<br />��� Sa�Nen1180Y pst aond�flmm. H �� �
<br />'i any� IemDrtg M the eauae Retfld
<br />� on pne a OUE TO, OR AS A CONSE�UENCE OF: �°� � d � h
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<br />� Enter tha UNOERLYWO CAUSE a) �
<br />�, � �
<br />(tOSease or (npoy thet.tnHletad
<br />�� tha eveMS resWNng in dearit) DUE TO, OR AS A CONSEGUENCE OF. ; onsetfn death
<br />LA87 +
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<br />1& PART LL OTHER 9IGNIFICANT CONOfI'IONS-COnditln�m wntHbudnB to the death 6ut not resuttfig in tlfe undmlqbtg cause 9h'en In PART L 1A WAS LAEDICAL E%AMIPJER
<br />-OR CORONER CONTAC7ED7 ...
<br />I � ❑ YES � NO
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<br />�� W ZO. IF FEEAALE: 27a MANNER QF DEATH 21b. IP TRANSPOR7'ATION INJURY 21e. WAS AN AUT6PSY PERFORMED?
<br />�i F ❑waa�ean�cwimu,a�+raa* �N� ❑rw��ae ❑a�ro�r�m, ❑ves �iuo
<br />� v❑areg�t et �nre ar aBaei+ ❑ n�mdene ❑ p�at� �n��+�a�on ❑ p�e��. a�a. w� numvsr Ftt�nuacis avaiwe�r_
<br />. ❑ NoY pfegnant, but pregnant xt(thlrt 42 days a! deafh ❑ s�aae ❑ Could not be detemdned ❑ Pec� TO CO�OPLEfE CAllSE OF DFATH7
<br />���I .0 []No.f P�9�4 h�ct W�� 43 days to 1 Y�betore death ❑�� (SP�NY) ❑ YES � NO
<br />l i� � �UnNnmvn M pregnant WithUi tha P� Y�
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<br />a 22a, aATE QF tNJURY (EEa. Day. Yr.) YOi. TtlNE OF INJURY 2ac. PLACE OF INJURY-At home, tann, street, tactuq+. oflice buO�nB. �o� site, e[e. (Spedry)
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<br />�' 0 22d. AiJURY AT WOAI(9 22e. DF.�RBE HOW INJURY OCCURREO
<br />}' ❑ YE8 ❑ NO .
<br />I 2�. LOCATiON OF II�LfllRY -BTREEf & NUMBER. APT. NO. CITYlfOWN BTATE Z7P COD�
<br />OF OFA?k! {�o„ �ay. Yr.y 24a. DATE SIGNED (A6o.. Oay. Yr.� 24b.11ME OF DEATH
<br />23b.
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<br />+H� I�o+ �Y� Yr.) 23c. TIA98 OF DEATH �� O 24e. PR6NOUNCED D6AD [NW.. DaY. Yr.) 24d. TIME�PRONWNCED OEAD
<br />• p iU ��►► Eaniaz m
<br />ast mmy tedga, demh occurte�i at the tima� dete and pfsce ���� 24e. On fhe besls ut examinetlon end/m imesdge8nn, in my aplatan deatM1 oocurted
<br />the ce�etel ( d Tplel a � � az enesuna. aam a�a �e aRa aua roare oawe[e►s�md;�sis�awce ane'n�►
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<br />fi. N7'1{?�UTE'7p THE OEATH?� ; 28a HA8 OROAN OR T188UE DONATION BEEM1I GONSIDERED7 266. WAS CONSENT GRANTED7. •.
<br />•, p.�o�x': ❑ un�xxowrt �,:, ❑ res �` No � anaari�zsn� u zea ta no p ves '�uo
<br />�.00_�a�s _� . �su�rs,r.�}�sta�asssssaerr .coR��,eas�c�oRC�i;r „ va;�rarauEV►cr „ �w�� 68 9 "-
<br />� �� �. _ � L� , �;-� - c�.� �. -_ o� ��� ���3i n� Mo� � �ah�.
<br />286. �ATE FlLEO BY REG(STRAR (Mo.. Oa�i. YrJ
<br />- �'�I� � � , ��"� � . � JUN � U 2011
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<br />'� rti�� �s d'acu�:ien to be a true co of an ori record on file with Vita1 Statistics, Dou as
<br />II� .�.�� „ PY � �
<br />C�ount� �esith Dep�t,,�f�malia, Nebraska.. Certified copies must ha.ve a raised seal in the area to the left.
<br />��produc��n �this gre:en certificate are not legal copies.
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<br />�� Date Issued: � 2 (� ��� � Registrar: •.. �`'�"°� � ...'° . ��
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