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WHEN TH/S COPYGARl�ES THE RAISED SEAL OF THE NEBRASKA H�'ALTHAND HUMAN SERVICES <br />S�YSTFJY� IT CFRTIF/ES THE 9ELOW TO BE A TRUE COPY OF THE ORIQ/NAL 1LE"WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVI�ES SYSTEM, {rlTAL STATI�S�� ICH IS <br />1�HE LEOAL DEPOSITORYFOR V1TAL RECORDS ; 4� <br />, � <br />dATE OF 1SSUANCE C , _ � N' �'�'' ' <br />F�� � 1999 201108702 ' ���6 .; <br />i ��ra����� � ,"� ` , : <br />uwcouv, �ewvsKa ►r�rHan��t�a�rs�ncFS,s�►s�� � Y � ' <br />STATE OF NFBRASKA- DEPARIMENT OF HEN.TH AND HUNIA�SER�I�C��?�AND, RT ',; <br />V1TAL STATlSTlCS � ` _ o u +� i <br />� CERTIFICATE OF DEATff �== ��-°=r�" �� � ° �• <br />t. DECEDENT - NAME FIRST . MIDDLE ' LAST 2. SEX °�».a, DATE OF DEATH /MaqA. D6y. Yeei1 <br />Fred�ick Charles Ehlers Ma.le 'Januar 2'4, 199� <br />4. CITV AND ATE OF BIRTH /d nd h US.A. nemB oambyJ � Ba. AOE • Lsst BNMay UNDER 1 VEAR UNDER 1 DAY . & DATE QF BIRTH �lMOn9t Oay. YBBrJ <br />O C ount y , N ebraska n��63 �b ""os. � oAYS Sc.HWRS' "�� December 29 19: <br />7. SOC� OSECURTIV NUMBER - - � -- -' - .-- - -� -- - . . . - . Be. - PLACE OF DEATH <br />� <br />- 36-2055 � I HosaRU: � �n orr�x ❑'w,�►w� <br />_ - - <br />8b. FACIUTY - <br />Nema ronuainsan�on,gWeadeerenanumeml _ I ' ❑ EAOu�tlea R�terce <br />St. Fxancis Medica l_Center ❑ °0A ❑ °tl7ef« <br />OR LOCA170N OF DEATH � 8d. WSIDE qTY LIMITS 8e. COUMV OF OEI <br />Ba. CITV.TOWN _ . .._ . <br />Grand Island, Nebraska ' Y� �"� ❑ I Hall <br />Ba RESIDENC ,• STATE � Bb. COUNTY 8e. CITY. TOWN OR LOCATION <br />Nebraska Aall Alda <br />f 0. RACE -(e.g.;' White� 81aek. Amer�an 4Wian. 71. ANCESTRY le.g_ daDen. Mencan. Glertne4 etcl ! 12 <br />a� <br />��� ��w�i �'�� American � <br />14a. USUALOCCUPATION (Qivek6d�wwkdanedwL�gmoS! O r�L.1 14b. KINDOFBUSINESSINWSTRY <br />- ot wakin9 a'e, ev� Hramed/ plf � <br />= Truck Dr3.ver Trucking <br />- - - - <br />' 18. FATHER. NAME .- . - � - _ FIRST . . . .AAIDDLE - -- � - LAST . .. _. _. ... 17. M <br />= Lester C.W. Ehlers I <br />nn <br />Yea � No � <br />NEVER <br />Frieda <br />Conege It �4 a 5•� <br />Oelke <br />WIDOWEU 13. NAMEOFSPi <br />DNORCED �r�13 <br />� 18. EDUCATION (Spe�eN�' � <br />°°me'rte" a <br />L <br />ST MIDDLE'. <br />M. <br />- 1& WAS OECEABED EVER IN U.S. ARMED FORCES7 18a WFORMANT-N .� <br />�Yes. �m. m unk) IB Ye% B� war and dame at eeMCee) <br />No ------- Maril nn Ehlers <br />79b. MFORAAANT . MAILING ADDRESS ISTREEf OR RF.D. NO.. CITY OR TOWN. 9TATE LPI � <br />P.O.Box 128 Ald a, Nebraska. 68810 <br />Not Embalmed <br />na FunlEaa� H� ME - NnMe <br />Livin ston-Sonde <br />72b. FUNERAL HpbfE ADDRESS (� <br />601 North Webb <br />_ 23. IMMEDIATE CpUSE <br />- �'"7 �r -tl�s� <br />� �e� - c�\ <br />_ _ . _ - _ _ f OH AS A CANSE4UENf <br />- UUE TO� <br />= ro) , �� <br />DUE TO: OR AS A CON$EOUENt <br />� � ' ' i. <br />PART `�� <br />I S h <br />28a 26b. <br />� AtciCBN � UMetermure0 ,, <br />� . SuicMe Pe�ing 28e. <br />�� HWnicitle � ImBa6gatron <br />= S � �., ,� ._. <br />276. DA'�E SIONED fMO_ Day. <br />_ ��� X �r � <br />-�� 27d. To Ne Dest o� my <br />� sl stetetl. <br />(s�¢�an�e ena rme� ► - <br />, 29. OID T08ACCOiSlSE CONTPoBUI� TO <br />21aMETHODOFDISPOSiTiON 21b. DATE <br />❑8� ❑�� Jan. 25, 1 <br />- 27d CEMETERY OR CREMATORV l <br />E. H. � �°"�'�' Gibb o e <br />RFD. NO_ CITY OR TOWN. STATE. ZIP) <br />Grand Island, Nebraska 68803-4050 <br />fENTER ONLY ONE CAUSE PER LWE FOR �a1. IbG AND �cp <br />���� <br />' < I c�e� <br />� <br />, <br />� Nlerval beht�n aiael eM de <br />i C 1 <br />� � <br />� <br />� ������ <br />I <br />(Ma <br />Yea � No � <br />27c TIME OF DEATH � <br />� � �(',U� <br />Me Wrre. tlate arM Wece ard tl� to tlre <br />YES� � NO � UNKNOWN <br />AD RESS OF CERTIFlER (PHYSICUIN, CARONEI <br />�. M��E n0_S. t�U <br />^ PART III IF FEMALE. WAS TNERE A 24. AUTOPSY 25. WAS GASE REFEfiFiEO lQ MtUI{ <br />PREGNANCY IN THE PAST 3 MONTH34 E%AMINER OR CORONERT <br />(A98610-54) Y88 No Y68 NO�.. V88 NO <br />RY _ ZBd. DESCRIBE HOW INJURV OCCURRED <br />M <br />�, farm. streel, lac�uy 2Bg. LOCATION STREET OA RF.O. NO- CITV OR TOWN STATE <br />.� 2Ba. DATE SIONED (Ma. Dey. Yr! 28D. TUAE OF DEATH <br />S� � � <br />28c PqpNpUNCED DEAO /Mo_ Dey. Yr.l 28Q PRONOUNCEO DEAD (Haau1 <br />1 M �� M <br />� <br />zee. on ure oasis a examination anE�« mve�aa0n, m my o� aeaM oeamea m <br />$ ere nme. date and Waze era oue m me oauseisl srema. <br />a�M Title <br />TISSUE DONATION BEEN D? T30b WAS CONSENT 6RANTED? <br />� YES NO I � � VES �_ <br />R YI lT Gr Pnnry � � <br />�,��� �: C��3 <br />OR <br />32a FiE61�RAR '" --- 32D. DATE FlLED BY FECi157RAR (Ma Day. �r.j <br />• JAN 2 7 �999 <br />