|
STATE OF NEBRASKA � " �.�`
<br />. • ����¢�� � _
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAtTf�,d ` �l l�i IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON F1ZE WITH THE NEBR.4,Sl�F���T,I�L�I+sF�' 60��1,'I��LTF! AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR=1/I+�L.I���S''•. �''y �. =
<br />?-.; � � , F �-.
<br />DATE OF FSSUANCE � �� �
<br />.:,� _ �. , t i� r a . ..
<br />S�A�L�Y,'' P K � = r Y' ,�� `
<br />06/30/2011 2 0110 5 8 7 5 p ���� " �� ����"� �� `���
<br />D�'f�7`ME'NT t7� f-1EE�77 H �f1/�� �J -�
<br />LiNCOLN, NEBRASKA HU�I� s��'�S' r ,�.,. ��=
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVI�ESr i j A �� Y�' � �;� �:'
<br />44 f19176
<br />CERTIFICATE OF DEATH � ` � : '� ; ,�r, � �� � � � ����`' _ `- � ' ' "-' " -
<br />1. DECEDENTS�NAME (First, Middle, Last, Suffbc) 2. SIX `: 3: DATE OF�DEATH (Mo., Day, Yr.)
<br />Grace Katharine Koepp Female June 24, 2011
<br />4.'CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(�'�•) MOS. DAYS HOURS MINS.
<br />Hastfngs, Nebraska 94 October 30, 1916
<br />7. 60CIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />506-05-4381 HoSPITAL � InpatleM OTHER ❑ Nursing HomelLTC � Hosplee Facllriy
<br />Bb. FACILITY-NAME (if not I�dtution, give street and number)
<br />� � ER/Outpatlent ❑ Decederrt's Home
<br />� P�imrose Retirement of Grand Island ❑ oon � otner (spectryyqSSISTED LIVING
<br />� 8c. CITY OR TOWN OF DEATH (Include 21p Code) 8d. COUNTY OF DEATH
<br />c Grand Island 68803 Hall
<br />� 9a. RESIDENCE-STATE 96. COUNTY 8c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />�7 8d. STREET AND NUMBER 9e. APT. NO. 8F. ZIP CODE 8g. INSIUE CITY LIMITS
<br />� 3990 W. Capital Avenue 68803 � ves ❑ No
<br />.$ 10a• MARRAL STATUS AT TIME OF DEATH Q Married ❑ Never MarNed 10b. NAME OF SPOUSE (First, Middte, Lasq Sufflx) If wife, give maiden name
<br />� ❑ n�►r�ea but separated � �nnaowea ❑ oiYOrced ❑ Unknown ,q�bert J Koepp Jr
<br />� 11. FATHER'S•NAME (Flrsq Middle, Last, Suffhc) 12. MOTHER'S-NAME (Firat, Middta, Matden Sumame)
<br />� Peter Tjaden Theda Brockelman
<br />fl ' 13. EVER IN U.S. ARMED FORCES7 Give dates W sarvice If Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />$ (Yea, No, or unk.) No Robert Kospp Nephew
<br />,� 15. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />� � Burtal ❑ DormUon
<br />Derek Apfei 1240 June 29, 2011
<br />❑ Cremadon Q E�om6ment 76d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 TOWN STATE
<br />❑ Removal ❑ Other (Specffy)
<br />WesUawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Ctty or Town, State) 176. Zip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUS OF D TH See Instruc lons and exam les
<br />18.�PART I. Enter the chain of eveMs-�dlaeases, InJu�ias, or wmplicatlonsdhat dlreeUy caused tlre death. DO NOT eater tertnlnai eve� aueh as cardiac arrest, � ; APpROXIMATE INTERVAL
<br />respiratory arrest, or veMrlcuiar flbrillatlon wkhout showing the adoiogy. DO NOT ABBREVIATE E�roaz only ooe cause on e Ilne. Add atltlftlonal Ilnes ff neceseary.
<br />IMMEDIATE CAUSE: ; o�et to death
<br />IMMEDWTE CAUSE (Flnal a) Cardlo Pulmonary Arrest ; Minutes
<br />disease m coiMitlon resul8ng
<br />i
<br />In tleath) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />s�y��h n�s ��amo�s, n b) Senescence i 94 Years
<br />any, leatling ta the eauae Iistad �
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: 7 orreet to death
<br />EMer the UNDERLYINO CAUSE C �
<br />(disease or inJury that InItlaOetl '
<br />the eveme resulting In death) _ DUE TO, OR AS A CONSEQUENCE OF: : onset t0 death
<br />usT . d}
<br />18. PART 11. OTHER SIGNIFlCANT CONDRIONS�Comlitio� contrlbuting M the death but not resulUng in the underiying wuse glven in PART I. 78. WAS MEDICAL IXANIINER
<br />� OR CORONER CONTACTED?
<br />� � YES ❑ NO
<br />W 0. IF FEMALE: 27a. MANNER OF DEATH 21b. IF TRANSPORTATION INJ 21c. WAS AN AUTOPSY PERFORMED?
<br />LL
<br />� �� NM pregnarR wHhin past year � Natural � HomlUde � DrivadOparator
<br />v � rr�e�rt asame ot aemn � n�aeM � Pendin9lmeati9�on ❑ Passen8er ❑ ves � No
<br />� � Not pree�. but pregnairt within 42 days ot death � Pedeetrlan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />� smaae � Comd na be aetermi�red TO COMPLETE CAUSE OF DEATHY
<br />'o Q Not Pre9�. but PreBnant 43 tlays to 1 Year before death � Ofher (SPecttY) � YES ❑ NO
<br />m � Unknown N pregnaM wfthin tha peat year
<br />E 22a. DATE OF INJURY (MO., Day, Yr.) 22b. T7ME OF INJURY 22c. PLACE OF INJURY•At home, fartn, street, factory, office bullding, cor�struction ske, etc. (Sp�iry)
<br />$
<br />.� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F�-
<br />❑ vES ❑ No
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CI'fYlTOWN STATE ZIP CODE
<br />23a. DATE OF DEATN (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.} 24b. TIME OF DEATH
<br />�' .� �� June 27, 2011 Approx. 02:00 PM
<br />� } 23b. DATE SIONED (MO., Day, Yr.) 23c. TIME OF DEATH � N� r 24c. PRONOUNCED DFAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />E z �� June 25, 2011 10:25 AM
<br />� �� � 3d. To the best af my knowied8e, death ocwrretl at the Ume, date antl place $ 1 5 � 24e. On the Aaele of exeminatlon anNor Imeatigation, in my apinion tleatA occurtetl et
<br />� and due W the cause(s) stated. (Signature and T(tte) $�� the Nrtre, tlffie and place and due ta the cau�(s) atatad. (SiBnature a+�d Titte)
<br />~ ~ g o Anne Eley, Hall Depury County Attomey
<br />25: DID TOBACCO USE CONTRIBUTE TO THE DEATH? 268. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. VqAS CONSENT GRANTED7
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN � YE3 � NO Not Appllcable ff 28a Is NO � YES ❑ NO
<br />27. NAME, TIT D DR O C RTIFIER (PHYSI , HYSIC I T ON�R'S IAN R O TY OR El� (7ype or PrlrK)
<br />Anne Eley, Hall Deputy County Attomey, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />28�. REGISTRAR'S SIGNATURE 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />June 29, 2011
<br />
|