Marcile KoltermanSTATE OF IOWA
County Record
STATE OF IOWA
IOWA DEPARTMENT OF PUBLIC HEALTH
DECEDENT
USUALRESI.
DENCE "1111
DEC-EFR
UYED.IFDEATH
OCCURRED INA
LONG EAU
C."to,"ITu.
HON. Give
INsnnrnoN
/ ADDRESS AS
RESIDENCE
PARENTS
W
".AME Marcile Kolterman
2. August 8, 2006
SEX
114
UNDER t YEAR
BIRTH NUMBER
DATE OF BIRTH (M._ Day. W.)COUNTY
CERTIFICATE OF DEATH
OS. DAYS
4bM.
_
TYPE
�: -Female
JY ars)
+a. r84
S.NOV• 23, 1921
6a. Pottawattamie
IN
DECEDENTS
FIRST
MIDDLE
LAST
DATE' OF DEATH fMo Day Vrl
PERMANENT
BLACK(NK
24a
-
HOSPITAL OTHER - y
Inpalienl C3ER/Oulpetienl ❑DOA ®Nursing Home 0 Residence [I Other (Specify)
E]-
WAS DECEDENT OF HISPANIC ORIGIN?
RACE -White. Black, DECEDENTS
FOR
INSTRUCTIONS
(Specify Noor Yes below)
American Indian, etc. fSpecifyJ
Elemenlar Y/S eco dory fO-121
-
College 11-4 or 5.1
If yes, specify Cuban: Mexican, Puerto. Rican. SIC,
I
T. 19 NO ❑ YES Specify., -
8. White 9.
SEE
HANDBOOK
HOUR OF DEATH
BIRTHPLACE -
CITIZEN OF. WHAT COUNTRY MARRIED.
NEVER MARRIED.
SURVIVING SPOUSE ((f wile. give made. mime)
atg
(City .Saik-j ntry)
-- WIDOW
;
DECEDENT
USUALRESI.
DENCE "1111
DEC-EFR
UYED.IFDEATH
OCCURRED INA
LONG EAU
C."to,"ITu.
HON. Give
INsnnrnoN
/ ADDRESS AS
RESIDENCE
PARENTS
W
".AME Marcile Kolterman
2. August 8, 2006
SEX
AGE -LAST BIRTHDAY
UNDER t YEAR
UNDER t DAY
DATE OF BIRTH (M._ Day. W.)COUNTY
OF DEATH
OS. DAYS
4bM.
HRS. MIN.
4g.
�: -Female
JY ars)
+a. r84
S.NOV• 23, 1921
6a. Pottawattamie
FACILITY NAME Of not institution, give slraet and number)
CITY. TOWN. OR LOCATION OF DEATH INSIDE
CITY LIMITS
6b. Risen Son Christian Villa e - --
I s..Councii Bluffs -
6ee Oeagr"°'
- 6e. PLACE OF DEATH /Check onlyone)
24a
-
HOSPITAL OTHER - y
Inpalienl C3ER/Oulpetienl ❑DOA ®Nursing Home 0 Residence [I Other (Specify)
E]-
WAS DECEDENT OF HISPANIC ORIGIN?
RACE -White. Black, DECEDENTS
EDUCATION fSp-ty-ty, highest grad. c.rnpieled/
(Specify Noor Yes below)
American Indian, etc. fSpecifyJ
Elemenlar Y/S eco dory fO-121
-
College 11-4 or 5.1
If yes, specify Cuban: Mexican, Puerto. Rican. SIC,
I
T. 19 NO ❑ YES Specify., -
8. White 9.
12 ('
HOUR OF DEATH
BIRTHPLACE -
CITIZEN OF. WHAT COUNTRY MARRIED.
NEVER MARRIED.
SURVIVING SPOUSE ((f wile. give made. mime)
atg
(City .Saik-j ntry)
-- WIDOW
;
EOREDcpecdy
_
Cie
S12A.
12b. _
_
SOCIAL SECURITY NUMBER
USUAL OCCUPATION (Give kind at work done during most
U=L
KIND OF BUSINESS OR INDUSTRY
WAS DECEDENT EVER IN U S ARMED
1a. 505-26-3712
working Iii Do mat use tired.)
14a, �iomema�cer
14b. Own , -Home
SEflVIC lSpeci(y yes or not
;5. o
RESIDENCE -STATE- COUNTYCITY,
TOWN. OR LOCATION
STREET AND NUMBER OF RESIDENCE
INSIDE CITY LIMITS
6!. Iowa (6b. Pott. 16C
Council Bluffs
16d 3000 Risen Son Blvd.
�
,cepC°" tVArn°'
ATHER'S .FIRST MIDDLE LAST
MOTHERS FIRST _ MIDDLE- MAIDEN
NAME -
17. - - Emmet - Prater
NAME
16. Greta Faye Thomas .
NFORMANTS -
MAILING ADDRESS (Street and Number or Rural Roule Number, Cdy or Town. Stale. Zfp Codn1
NAME -
19A• Karen Heintzen
,9b. 3914 Tumblewood Court, Lawrence, KS 66049
Oa. METHOD OF DISPOSITION -
PLACE OF DISPOSITION (Name of Cemetery. Crematory.
LOCATION (City or T.W.. Stale)
11 Burial ®Cremation -. C1 Removal from Slate
or other place)
-
0o.nabon 0Other(Spacrfr)
20b. Elmore Crematory
Zoe. Omaha, NE
-FUNERL CTD SI ATli- - ..-_--. - _....._ - - _ _ _..... .- -..---_..:-_
FO-LICFNSEA - -.
21 a. ®
21b.
carica. laueei aria a.vmver u. mural Havre ivvm.er, a.i,y yr ivwn, �,aie, uP I...I I
�.IEITAAF1-.IGMr
s. Cutl r-O'Ne 1 -Me er-Woodring Funeral Home, 545 Willow Ave, Council Bluffs, IA 51503
0;!r A IPl i�'
��
(DMaEMy11171EQ BYR
- '-
�i
_
22b. f1V V 1 11 LOO�AH
J. OF ATH
GATE OF INJURY
HOUR OF INJURY
INJURY ATWORK?
DESCRIBE HOW INJURY
OCCURRED -
�MANNER
[�F4aturai ❑ Pending
(Mo.. Day. Yr.J
(Specify yes or no)
9
21a.
24b. M.
24a
24d,
❑Suicide Could hot
❑ Suicide ❑Could not be
PLACE OF INJURY at home. larm. Strael.
LOCATION (Street and Number or Rural Route Number. City or Toan. Stale Z,p Codec
[I Homicide
factory, office building Ic.)
.dalermmad
tae -
241
.
To the best of my knowledge, deo ccurred at the D e ate a Ce due to the causes) and manner as stated.
DATE SIG D fMo., Day. r
HOUR OF DEATH
28a. (Signature end u6e)� G
25D
�7
25.1 -7 A ,M
NA ME AND TITLE OF ATTE DING PHYSIC! IF HERT CERTIFIER(Type/PrinU
26.
NAME AND ADDRESS OF CERTIFIER (Physician or Medi Examiner) (Typetpent
2T. Dr. Bernard Hill er, M. ., 10905 Cottonwood Lane, Omaha, NE 68164
2e. PART I. Enter the dlaeaSes. inluties, or complications that caused the death. Do not enter the mode of dying, such as cardiac of respiratory arfesl. 1 Approximalo
shock, or heart failure List only one cause on each line. f Interval Belween
S Onset and Death
Final disease or contlition�iil, 1A: OIATECAUSE --
resulting in death - -
(5)
a U O(OH A ONSEOUENCEOF
f Sequentially list cond�Dons. l'. (b)21
leading to immediate CaU3¢. En1¢r TO AS A CON UENCE OFT,
UNDERLYING CAUSE (D,Seaa2 Or -
injury that initiated events resulting (c) -
m death) LAST. DUETO (OR AS A CONSEOUENCE OFY
(d) - - -
PART II a. Other significant cond II4ns contributing to death but not resulting in the 1 b. IF FEMALE, WAS THERE A AUTOPSY WERE AUTOPSY FIND-
( underlying rouses given to Pan 1. PREGNANCY IN THE PAST 12 fS ecif
p y yes or no) TO C AVAILABLE PRIOR
f MONTHS TO COMPLETION OF
CFN 588-0021 1 (Specify yes or no) CAUSE OF DEATH(
i - (SO cdyyes."no)
Revised -1/8.9 1 (/ 29a. 29b,
(TSI
This is to certify that this is a true and correct reproduction of the original record as recorded
in this office, issued under authority of Chapter 144, Code of Iowa,
!!JJf
This copy not valid unless prepared on engraved border displaying state seal and signature of the Registrar.
AUG 112006 BY a OF PoTrAWATT ?�
e a �r
q DATE ISSUED CO WTY REGISTRAR OF VITAL RECORDS COUNTY �t
08 sC; x
cnoae o n npn rni ronncl WARNINf;•.IT IS If I FC:AI Tri miPI ICATF THIR (nPV
1 �O.'�•' •"'•"r Y
IOWA y
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