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<br /> - W/fN THS COPY GUt/�3 Tif RA/SED SEAL OF THE NEBRASKA HEALTH AND HUMAN��=.�
<br /> S1^S7EA�IT(�RTF�31}E BELOW TO 8E A TRUE COPY OF THE OR/O/NAL RECORD Q�'-- =-
<br /> THE NEBRASKA HEALTH AND HUMAN 3ERVICE3 3Y8TE11�VRAL 8TATISTiCS.BEC __ �'���:��"'�
<br /> THE LEOAL DFPOSfTORYFQR VITAL I�CORD�, . �'.=-��� _
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<br /> DATE OF IS3UANCE ^���'S;��`. -�: _
<br /> MAR 2 :� 1998 ,uvi:�-��R=-... : '� ,
<br /> UNCOIJI�NEBRASIU ASS/STANT STAA�`REQ�RAR � ��,-x
<br /> r�t.rrr�r�s�s�� _ � .
<br /> ....._1 � - ...�..��Y �= f'�� .,..,
<br /> • STATE OF NESRASKA•D�ARI'l�NF OF HEALIH AND HUMAN SERVICBS FINqN($,��,t�ppA7ti_.�?�` ?
<br /> VfUL STA17371CS �f�l+.r "y►R-'- _ " � �
<br /> CERTIFICATE OF DEATH '�"°�� �:
<br /> i.oECeo�n-wwE . Fr+sr Mroae usr , z.sex a o�re ;:q,�.,�r..ti :,
<br /> .;�-:. ,
<br />. Elmer Frederick Dibbern Male Februgry 16, 1998
<br /> ♦GTY AND$TATE OF&RTN /I npl1�U.S.A.irn»cpiy�/ St A6E•WI BYtld�y UNDER 1 YEAp UNDER 1 DAy 0.DATE OF 81RTM r�ar.r..r�
<br /> Wood River, Nebraska ��� 91 5° �'1OS i °AVS �`M011R8� """S
<br /> June 07, 1906
<br /> 7.SOCIAL SECURTIV NUMBER M.PIACE OF DEATH ,
<br />• SO&140890 HosvRw ❑ m,r.,,, o,►�� � r�w�,b,,,�
<br /> - � �e.c�m-wm. ��a.w��r,np+.asN.�e�� ❑ ENOu1p�INry � nna.�c•
<br /> , Titfany Square Care Center ❑ oo� � a,,,,,�,�,
<br /> x crtr.rown oa�oc�ran oF n�r►� . se. cm uums a.cou+rY oF o�tM
<br /> Grand Island �.. � ►w � Hall � �
<br /> Ya NESIOENCE-STATE 90.COUMTV Yc CrtY.10WN OR LOCAl10N �... � 90.STREET D NUMIBER./tie�pirq ZO CoaU/ W.INSIOE GTY LIMITS
<br /> Nebraska Hall Grand island 716 S.Sycamore ,68801 �..�X ��
<br /> 10.RACE-N.q..YNwN.&ack.Mwiun kdian. �1.ANCESTRV lap..O�Y�n.tMicitan.fiwm�n.Ncl � t2.�MARPoED a M/IOOYVED 1�.NAAAE OF SPOUSE /N w+M.P'w m�iaWr nrrwl
<br /> ��e� �A�merican "E`�R ��E� Miidred Wiese
<br /> IK d»ont faYUS�ronMnM�d/ kinddMCrkAsraY�ipnan 'A�I 1�D.KINDOfBUSWESSMIDUSTRY O 15.EDUCATION ISPSCMo^M�p W�ca�dMa01
<br /> Carpenter 5"�� Seif-Em lo ed E"m°9""°'S"°�a"Y�o�'z� ' �ow�n.�p s-�
<br /> 16.FATHER-NAME FiiST � MIOOIE UST 11.MpTMER iUiST MIppLE MAIDEN SURNAME
<br /> Ernest Dibbern Au usta Kroe�er
<br /> 18.WAS DECEASED EVER 1N U.S.ARMED FORCES? �O/OHI�I43- �����NT-NAME
<br /> 1�'�s.ro.a uikl In yss.giva war uitl Wiss d�a� .
<br /> Yes World War I[ 10/19/1945 Mildred Dibbern
<br /> � �90.MIFOAMAMT MAIUNO AOORESS �ISTREET OR R.F.O.NO..CI7Y OR TOWN.STATE.ZIP� � � . ---
<br /> 716 S.Sycamore,Grand Island,lYebraska 68801
<br /> 20.EMBA�MER-$qNATURE 8 UCENSE NO. 21a METlIOp QF q$Pp$1Tlpfy 210.OATE 71c.CEMETERY OR CREMATOqY NAME
<br /> � ' �e�w ❑�.�,,,� 02/18/1998 Grand Island Cit Cemeter
<br /> a.FUNERA�HOME-N E • 2t4.CEMETERV OR CHEMATpRV LOCATIpN CI7r OA TpWN � STATE
<br /> �
<br /> Apfel-Butler-Geddes Funeral Home ❑�� ❑�� Grand Island,Nebraska
<br /> 22b.FUNEML IqME ADDRESS �STREET OR R.F.D.NO..Ct7Y ON TOWN.5?ATE.ZIP)
<br /> 1123 West Second Grand Island,Nebraska,68801-5899
<br /> 2J. IMMEqAtE CAUSE �ENTER ONIV ONE CAUSE PER UNE FOR la6(D�.ANO(cp � MNS�va�beh.een oeset and oeam
<br /> PART Q
<br /> I `v�d/�/� ~
<br /> lal /J:rC,//�D/f/�. I
<br /> � WE T0.OR AS A CONSEOUENCE OF i kwerva�benrasn pnx�ana aeain
<br /> � �',�+ i
<br /> ��) //� �r /�G � �i�•�.y � •
<br /> DUE 70.OR A$A CONSEOUENCE OF�
<br /> � MiMrvai Wtwe�n onsM ara xa�^
<br /> J I
<br /> (" � J /c�/j/ J//t,.i���� •-
<br /> OTNER SIGNIFICANT C DITIONS•CpiAilqM ' �
<br /> PART ����q b Ma AeaNi bul rql ra • PART I�1 IF FEMALE.WAS THERE A 2� AUTOPSV 25.WAS CASE REFEARED TO MEDICAL
<br /> N �'�G ���Jc��j�'����� �� PR GNANCY IN THE PAS?3 MONTMS?
<br /> E%AMINER OR CORONER�
<br /> � Apas�o•Sal rm No vss No rss p�p
<br /> �. 28D.DATE OF IWURY /Mp..p�Y.Yi./ 28C.110UR OF INJUHV 28d.DESCRIBE HOW INJUHV OCCURRED
<br /> � Acc�tlen � UMerormned
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<br /> � ❑ �K� ❑ P�^9 ZBs.IWURY AT WORK 261.PtACEQF IWNU�qY%N __ ,lum,shsel.laCby 2gq.LpCq710N STREET OR R.F.O.N0. CITV pR TOWN STATE
<br /> ❑ a dFCa dMd�¢ spKql%
<br /> ❑ MomiciES Invesigalan yay �
<br /> 27� DATE OF OEATH /Mp.,play,yi./ . 2Bi,OATE SIGNED (MO..Wy.YrJ y9p TIME OF DEATH
<br /> � February 16, 1998
<br /> �a 27D DATE SKiNED (Ab.Dry.Yr,/ 2lc TIME OF DEATM a��� 2Ec pqpNp�NCEO DEAO /Ab.Wy,Yr./ 260,pRpNOUNCEO DEAO lhbwi M
<br /> �� February 16,1998 9:14 AM M ����
<br /> s� z�o To ms ees�a k � � M
<br /> ^q' mwNAqs.Asnh unea a�tM' tlate ua mtl Oua b tM 2Es.On ms Gsia ol a�aminatan and�a invMlqatbn,in mY apnan dsalA otcurrW at
<br /> eausale��ta�eA. ~u ti ma ume.Oaa erM
<br /> Wae arM tlue b�M auae�fl WNO.
<br /> IS�naturo an0 Tiqs � �„/ i.��i
<br /> 49.d0 TQgACCO USE CONTRI T T DEATH7 (S natwe an0 TNo
<br /> JO.�HAS ORGAN OR TISSUE OONATqN BEEN CONSIDEREO? 30.b WAS CONSENT GRANTED�
<br /> � �ES � � UNKNOWN � VES NO ,
<br /> � � YES �NO
<br /> 3t.NAME ANO AODRESS OF CERTIFIER(PHVSIqAN,CpqpryEN�S PHVSICNN OR COUNTV ATfORNEYI lType a PrnK)
<br /> Jane A McDonald, MD, 800 A a Street, Grand Island Ne 68803
<br /> • 32a.HEGISTRAR
<br /> J2b.DAiE FILED BV REGISTRAR /Mp,Day Yr/
<br /> FEB
<br /> Exhibit "A" �
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