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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTNIENT OF
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSTTORY Ft
<br />DATE OF ISSUANCE
<br />12/30/2011
<br />�012004�0
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN
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<br />GERTIFIGATE oF DEATtI � � ' �.�'; .. ' ' • � � : : . `+, r.`';' .:`"
<br />1. DECEDENI"S-NAME (Flrst, Mlddle, Last, SuffUc) 2. SEX ��'� �.. AT`EE F DEA'CH'fMo., Day, Yr.)
<br />Marceina M HeROId Female �' �.D,.ecember 14, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF B1RTH Ba. AGE - Last Birtf�day b. UNDER 1 YEAR 6c. UNDER 1 DAY' 8. DATE OF BIRTH (Mo., Day, Ya)
<br />(YBd MOS. DAYS HOURS MINS.
<br />Aurora, Nebraska 88 September 24, 1923
<br />7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />505-22-9013 HOSPITAL � Inpatlent OTHER ❑ Nuraing HomelLTC � Hoepiee Facility
<br />8tr. FACILITY•NAME (If not InsUtutlon, give street arM numbe� ❑ ER/OutpaUerrt � DeeedeM's Home
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<br />� 4037 Buckingham Drive ❑ DOA [j Other(specliy)
<br />� Sa CITY OR TOWN OF DEATH (Inciude Zlp Code) Bd. COUNIY OF DEATH
<br />'c Grand Island 68801 HaU '
<br />� ea. RESIDENCESTATE 9b. COUNTY 8c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />� 8d. STREET AND NUMBER 88. APT. NO. 8L ZIP COOE 8g. INSIDE CITY UMITS
<br />� 4037 Buckingham Drive 68801 � res ❑ No
<br />'° 10a. MARRAL STATUS AT TIME OF DEATH � Marrted ❑ Never Marrled 10b. NAME OF SPOUSE (Flrst, Middle, Last, SuHi�c) H wHe, glve malden name
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<br />� ❑ nnemea but separated ❑ �nndowed ❑ owor�d ❑ u��own Kenneth M Herrold
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<br />11. FATHER'S•NAME (Flrst, Mlddle, Last, Suffiz) 72. MOTHER'S-NAME (flrst, Mtddle, Malden Sumame)
<br />� David S W Carlson Laura E Hunt
<br />� 13. EVER IN U.S. ARMED FORCES? Give dates otservtce HY�. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ nes, No, or unk.� No Kenneth M Herrold Husband
<br />$ 15, METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F ❑ Burlal ❑ Donatlon
<br />Not Embalmed December 15, 2011
<br />� Cremadon Q Errtombmerrt �gd. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />� Removal � Other (Specify)
<br />Central Nebraska Crematlon Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, &tate) 17b. Zip Code
<br />Kleine Funeral Home, 3213 W. North Front Street, Grand Island, Nebraska 68803
<br />CAUSE OF D TH See Instructlons and exam les
<br />1& PART I. EMarthe chafn of eveirts-�dlseasea, inJurles, or wmpticado�dhat dlrecUy nused the death. DO NOT errter tertNnal eve�rte �ch as cardiec arreat, � APPROXIMATE INTERVAL
<br />respiratory artest, or vaMriwlar flbdllaUon without ahowl� Gre etlology. DO NOT ABBREVIATE EnDar onry o�re cause on a Ilrte. Add add(tlmml It�re81( �ary.
<br />IIWMEDIATE CAUSE: ; onset to death
<br />IMMEDIATE CAUSE (Flnal e) Progressive Parkinson's Dtsease s Years
<br />�Isiaee w conamon reuuttine
<br />� d � ) OUE TO, OR AS A CONSEQUENCE OF: = oreet to death
<br />seq�em�nr ��s �nmuo�, n b) Severe Osteoporosis t Years
<br />ai1y, leatlinp to the cause Ileted
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<br />on Nre a DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />�rure �mners�nNO cause �) ChroNc Pain / Frallty ; Years
<br />(dfsease or InJury that Inklated
<br />tlie eveMa reswtlng In de�h) DUE TO, OR AS A CONSEQUENCE OF: � anset to death
<br />`as� d) �
<br />18. PART p. OTHER SIGNIFlCANT CONDITIONS�Comiltlor� conUl6Wng to the death but rrot reaultlng In the umlerlyinp causa ghen In PART I. 18. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />a , � YES ❑ NO
<br />W o. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERPORMED7
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<br />� � Not Pre9nant wkhln Peat Year � NaWral � HomIWAe � OriveAOperaWr � YES � NO
<br />W � Pregnant at tlme ot tleath � Passen8er
<br />V � Aalde�rt � Pending Investlgadon
<br />a � Not preg�mM, but pregnain within 42 deye of tleath gmdae Cowd not be determined � P��" 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />❑ ❑ TO COMPLETE CAUSE OF DEATH?
<br />� Wot P�eB�, but pregna�rt 49 days to 1 year before death � Otliar ($P�Y)
<br />� ❑ Unimown B P�e9�t witthln the P� Yeaz ❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIdIE OF INJURY 22e. PLACE OF INJURY•At home, farm, street, faetory, offiee buUding, coimtructlon site, ete. (SpecfTy)
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<br />.� 22d. INJURY AT WORK4 22e. DESCWBE HOW INJURY OCCURRED
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<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYlfOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a, DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />�� ��� December 16, 2011 Approx. 01:00 AM
<br />E 23b. DATE SIGN�D (MO., Day, Yr.) 23c. TIME OF DEATH ° 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
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<br />U Z � 6<� December 14, 2011 07:31 AM
<br />$ e� � . ro ue 6ess or my w�owtea6e. aeasn ouurred asure ame. mee ana Piaw $ �°
<br />$- and due to tlre cause(s) stated. (9lgnafure antl Title) f� ��' ��� m axaminaUon and/or ImesBgatlon, in my opinlon death occurred at
<br />F � F& � Ne tlme, date and p�ace and due to the cauw(e) emted. (Signature and TIUe)
<br />� s Sarah Carstensen, Hall Deputy County Attomey
<br />2S. DID TOBACCO USE CONTRIBUTE TO THE DEATHY 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIOERED? 26b. WAS CONSENT GRANTED?
<br />❑ YES ❑ NO ❑ PROBABLY � UNKNOYYN ❑ YES � NO Not Appllcable H 28a la NO ❑ YES ❑ NO
<br />2. TIT E R IFI R(P I I T T, R R P Y I UNTY ORNEY) ype or irt)
<br />Sarah Carstensen, Hall Deputy County Attomey, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />28a. REGISTRAR'S SIGNATURE � 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />December 30, 2011
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