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STATE OF NEBRASKA
<br />VPIHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASK,4 DEPARi'MENT OF HEALT�;f ;�ISIQ � s UMAN ��'RVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NfBRA.��, QL�PI{�TM QF W�AL�H AND
<br />�A
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY �'Oa t°IT�A R�'�(^�� . �: "
<br />,"' . • r�� ' � �,
<br />DATEOFISSUANCE ��/��A�� ,,�'�+" << .
<br />04/18/2011 2 012 0 0 0 9 5 Sr S �C'Op�ER rr ���; �'�
<br />r : A$�.I�TI•II1lT���"TiQT-�'��`Gg�7`RAR ;, 'a � , ;
<br />'' GEJ�.�U2�ENT OF HEALT�I ANC), � ,��
<br />LINCOLN� NEBRASKA f�(II�A'�ER.�� , f a -, ' - •r
<br />� � A ` �07/ A •,.�44 �' . .
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVI�k�� <,�� p'�•..: f+ c_� •" 19 01172
<br />GEKTIFIGATE OF DEATFI ' �U �, " +J� A^ yr 1 � .-� �
<br />1. DEC�DENTS-NAAAE (Flrst, Middle, Last, Sufflx) 2. SEX ° .3.,D/hTE,QF 6EATH:(Mo., Day, Yr.)
<br />Kirli Lee Perrelet Male Apr117, 2011 �
<br />4, CITY'YW D STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo.; Day; Yr.)
<br />(1r�•) MOS. DAYS HOURS IVONS.
<br />Omaha, Nebraska 60 December 18, 1950 '
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />508-68-1254 H�Sp T�,IA � InpaHerrt I OTHER ❑ Nursing Home/LTC � Hospice Faclittyr
<br />Bb. FACILITY-NAME QI not hretfh�tlon, give street and number) �p
<br />� ❑ ulpetleM ❑ DecedeM's Home
<br />� Saint Francis Medical Center ❑ ooa ❑ ar�e■ �speciry�
<br />� BC. CITY OR TOWN OF DEATH pnclude Zip Code) Bd. COUNTY OF DEATH
<br />c �� II Grand Island 68803 Hall
<br />� 8a. RESIDENCE-STATE 8b. COUNTY 9c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />� 9d. STREET AND NUMBER . APT. NO. 9L LP CODE 8g. INSIDE CITY UIVOTS
<br />307 5 S camore 68801 � rES ❑ No
<br />� 1Qa. MARIT/LL STATUS AT TIME OF DEATH � Married ❑ Never Marrl�i 10b. NAME OF SPOUSE (First, Mlddle, Last, SuHirz) H wife, give malden rmme
<br />€ ❑ Mamea but separated ❑ wndowed ❑ onrorcea ❑ unicnown Georgia Marie Harms
<br />� 71. FATHER'S-NAME (Flrst, Mlddie, Last, Suffhc) 12. MOTHER'S�NAME (Firat, Middle, Malden Surr�me)
<br />Tell Henry Perrelet Frances Leona Gunsolley
<br />E 13. EVER IN US. ARMED FORCES? Give dates of eeMCe MY�. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ �ras, No, or unk.) No Georg(a Marfe Perrelet Wife
<br />,$ 18. METWOD OF DISPOSITION 76a. EMBALMERSIGNATURE 18b. LICENSE NO. 78c. DATE (Mo., Day, Yr.!
<br />� ❑ Bu1�ia1 ❑ DormUon
<br />Not Embalmed April 9, 2011
<br />� CremaUon 0 Entombment 16d. CEMETERY, CRENUITORY OR OTHER LOCATION CffY / TOWN STATE
<br />❑ Remorai ❑ o�ner (speciry� �ntral Nebraska CremaUon Servlces Gibbon Nebraska
<br />17a. FUNERAL HOMB NAME AND NL4ILING ADDRES3 (Streat, Ctty or Town, State) 17b. Zip Code
<br />AII F2iths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CA E F DEATH See instructlons an exam les
<br />78. PART 1�: Frrter the chaln M evems�.dieeasea, inJudes, or aompllaatlo�mat dUeetiy ceused the death. DO NOT e�rterterml�l eveirt.s such pa cardlac erteffi, ; APPROXIMATE INTERVAL
<br />reaplr,aWry arteat, or veMHwlar flbrillatlon without ahowinp the etlolog�r. DO NOT ABBREVINTE E�rter only o�re ceuse on a Il�re. Add edditlonal Il�ree B necesaary. i
<br />IMMEDIATE CAUSE: ; a�et to death
<br />„n,e�oa�e cwsE �,,,,a, a) End Stage Chronic ObstrucUve Pulmonary Disease With Respiratory �ailure ; One Week
<br />dlBeaBe q► condWon reeultl� . �
<br />1O �'� DUE TO, OR AS A CON9EQUENCE OF: � orreet to death
<br />seq�e�ny i�at �o�a�uo�, it b) '
<br />�,y� ieaamo to nre cause pama
<br />on Me a. DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />EMer Me uNDERt.Y1NG CA11S8 �� �
<br />(dieeaee or InJury dmt intflafed '
<br />tlre evenm rewidnp in death) DUE TO, QR AS A CONSEQUENCE OF: : onset W death
<br />� d)
<br />18. PART II.OTHER SIGNIFlCANT CONDITIONS�Comlitloire corMlbuting to the death but not rasulting In the undetiyt� eause gNen in PART I. 79. WAS MEDICAL EXANONER
<br />OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />LL O. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21e. WAS AN AUTOPSY PERFORMEDT
<br />� � NotprepnaMwithln �tyear � NaWrel � HomiGde � Drfver/OperaMr
<br />LLI Preghentattlmeotaead� ���� ❑ �S � NO
<br />V � � AcdderR � PenUlnp Imesdpadon
<br />� Not preprmnt, 6ut prepnaM �rkhin 42 daye of death � Pedeatrlan 21d. YYERE AUTOPSY FlNDINGS AVAILAB
<br />I.�' ❑�� ❑�� ^Of � d ��"� TO COMPLETE CAUSE OF DEATH7
<br />� � Not preBneM. but P�e9naM 49 daye to 1 Year before deatb � Otlrer (SPecih�)
<br />., � ❑ UNalown N P�eBnant withln the P� Y�► ❑ YES ❑ NO
<br />E 22g: DATE OF INJURY (Mo., Day, Yr.� 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, oftice bullding, eoneWctlon alta, etc. (Speel(y)
<br />$
<br />� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />❑ ves ❑ No
<br />22f. LOCATION OF INJURY - 3TREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo„ Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />� April 7, 2011 B � �
<br />�� 23b. DATE SIGNED (Mo„ Day, Yr.) 23c. TIME OF DEATH �� 24c. PRONOUNCED DEAD (Mo„ Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />g„ o ' A ril 8 2011 01:10 PM �<�
<br />� To tde Eeat M my knnxleUge, tl�th oeciared at the time, date mM pUce ��� zqe, On the baste Me�minadon anNOr Imestlpadon, ln my opinlon death occuned at
<br />� end due to the rauee(s) atated. (8lBnah�re antl Title) � Z the tlme� date arM pidee and due to the muse(s) atated. (Slqnahne and TIUe)
<br />~ Richard Fruehling, MD ~ $ $
<br />25. ID TOBACCO USE CONTRIBUTE TO TH8 DEATH? 28a. HA9 ORGAN OR TI9SUE DONATION BEEN CONSIDEREDT 28b. WAS CONSENT ORANTED?
<br />(� Y�S ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applicable It 26a is NO ❑ YES ❑ NO
<br />2. TITLE AD ERTIFI R Y R (Type or PrIM
<br />Richard Fruehling, MD, 2116 W Faldley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIONATURE � 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />April 11, 2011
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