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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL
<br />THE BELOW TO BE A TRUE COPY OF THE' ORIGINAt RECORD ON FILE WTfH THE NEBRAS
<br />HUMAN SERVICES, VTfAL RECORDS OFFTCE, WHICH IS THE LEGAL DEPOSITORY FOR�l'
<br />' � � , ' / �_ �. .
<br />DAT� OF ISSUANCE
<br />08i15/2011
<br />2 Q �. 2 014 �;�' �
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVI��S`� n
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<br />CERTIFICATE OF DEATH ; :, ; "�' ; ;--,,- %`:��' ��` - • ---- -
<br />1. pECEDENT'S-NAME (Flrst, Mlddle, Last, Sufflx) 2. 9IX �„ ;, r 3 d'AYE �,A�cTH (Mo., Day, Yr.)
<br />Doris Hazet Zuehike Female -�- -`' Rug(is�£9,2011
<br />4. IlY AND STATE OR TERRITORY, OR FOFtFJGN COUNTRY QF B1RTH Sa. AGE • L.aet BI►ttbay b. UNDER 1 YEAR Sc. UNDER 1 DAY B.�ATE OF BIRTH (Mo„ Day, Yr.)
<br />(YB•) MO3. DAYS HOURS NONS.
<br />Grand Island, Nebraska 82 May 9,1929
<br />7. SOCIAL SECURRY NUMBER 8d. PLACE OF DEATH
<br />507-32-8346 PIT ❑ I�aUe�rt OTHER � Nursing Home/LTC � Hoapice Faciiity
<br />8b: FACILITY•NAME (ii not Ir�tid�tlon, give street and number) � ERlputpatlent ❑ D��e�Rs Home
<br />�
<br />� Tiffany Square Care Center ❑ ooa ❑ ocner (s�iry)
<br />� 8c. ¢ITY OR TOYYN OF DEATH (Include Zip Code) , Sd. COUN7Y OF DEATH
<br />e Crand Island 68803 Hall
<br />� 8a. RESIDENCE-STATE 8b. COUNTY 8c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />� 8d. STREET AND NUAABER 9a APT. NO. 8L ZIP CODE 9g. WSIDE CITY LIdU7S
<br />�` 2212 West 11th Street 68803 ��s ❑ wo
<br />.g 10a. MARITAL 37ATU3 AT TIME OF DEATH � Marrled ❑ Never Martied 1�b. NAME OF SPOUSE (Fhst, NIIddte, Last, Sufff:) IT wiie. give r�iden rmme
<br />� ❑ d�amea nut separaeed � �nnaowed ❑ onrorced ❑ unknown Louis H Zuehlke
<br />� 17, FATHER'S•NAME (First,, AlUddle, Last, SuHbc) 12 MOTHER'S-NAME (Fhat, Mlddie, Malden Surname)
<br />Alton Cart Mderson Olga Christine Henne
<br />� 93: EVER IN U.S. ARMED FORCES7 GNe dates of service H Yes. 14a. INFORNUWT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ (res, No, or Unk No Diana Edwards Daughter
<br />,� 1S. METHOD OF DISPOSITION 18a. ENBAI.MERSIONATURE 18tr. UCENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />� � surta� ❑ uonetlon SCOt DBWitt 1163 August 12, 2011
<br />❑ Crematlon � ErRombmerrt 76d. CEdIETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />����� ��� WesUawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, CHy or Tow�, Stete) 17b. Zip Code
<br />Kleine Funeral Home, 3213 W. North Front Street, Grand Island, Nebraska 68803
<br />CAUSE OF D TH ee instructions and exam es
<br />1& PART L E�RO►llt9 chaln M eva�rie•-0Ieeasea, Inl���& a/ �P��o�� �Y ���• � NOT eMeitermUral eve�AS euch a8 wrdlao erteet,� i APPROXIMATE INTERVAL
<br />�V���Y evest, ot ieentricWaz 9brillaflon �rMhout shawUB thB etlology. DO NOT ABBREVIATE Fster oAly O�re eeu8e on e MB. Add additlm�al Unes H�ry.
<br />�re
<br />IMMEDIATE CAUSE � o�et to death
<br />�nn�ourE cnuse ��e� e) Glioblastoma MulUformae E Months
<br />dlsease or wnd�lon reaul8ng� � - - . - . .
<br />1O �� DUE TO, OR AS A CQNSEGUENCE OF: � o� � d��
<br />SequeMlalry Ilst eondt6one, N b) � '
<br />i
<br />em.188tling M the �ueB 1180Btl -� i
<br />on mre a DUE,TO, OR AS A CONSEQUENCE OF: � a�et to death
<br />EMer the UNDERLYING CAUSE �� . ..
<br />(AiBeaseorinlwYthetinidatetl . . . � . . i
<br />� e �� �" �'� DUE TO, OR AS A CONSEfiUENCE OF: : o�et to death
<br />LAST d �
<br />18. PART A. OTHER SIONIFlCANT CONDITIONS�Comlitlo�m cantributi� to the death but rrot resulUng In the uadsNyi� cairee glven In PART 1. 19. WAS MEDICAL EXAAI�NER
<br />Rheumatoid Arthrids, Atrial Fibrlila8on, Hypertension, Hypothyroidism OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />u , 20. IF FENIALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WA3 AN AUTOPSY PERFORMED?
<br />� � NotpregnarRwRhln��Ye�� . '� �NaWrel �HOmicide �DrIveAOperator � ❑ � �
<br />w Preenaneatamewaeam ���� NO
<br />C � � AxlflaM � Pandln8lmeati8atlon
<br />Q Not pregnam, but pre9na�u w�th�n a2 days ot death Sutdde Cowe iwt be detenNned ❑ P��" �d. WERE AUTOPSY FlNDINGS AVAILAB
<br />a p� n�e�. ow o� as a� m, r�• �re a�n, � � "° ❑ or� �sv�» TO COdIPLEfE CAUSE OF DEATH?
<br />� Q unimown B nreenant wnhin the pest rear . � - �❑ YES ❑ NO
<br />E?2a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, famy street, iactory, oitiee buliding, eor�structlon site, ete. (Spacify)
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<br />.� Yl�. INJURY AT WORKZ 22e. DESCRIBH HOW INJURY OCCURRED
<br />F�
<br />❑ves_ pN0
<br />22P. LOCATION OF INJURY - 9TREET $ NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />29a. DATE OF DEAtH (Mo.. Day, Yr.j �" 24p. DATE SIGPFED (Mo., Day,�lr.) 24b. TiN� OF OEATH - --
<br />S August 9, 2011 S�
<br />� Y 23b. DATE SIGNED (Mo:, Day, Yr.) 23c. TIM1I� OF DEATH � k Y 24c. PRONOUNCED DEAD (Ma, Day, Yr.) 24d. TIAIIE PRONOUNCED DEAD
<br />�, Z Au ust 11, 2011 06:08 AM � a�
<br />° ° sae. on are �s a m�un�on aumw uneaneanon� m mr on�M�, mau, �ea es
<br />To tfre bee! ot my knwrteABe. deatb oaurted et tha tlme, date arM Place
<br />aM
<br />8 ana aue eo ene eauae(e) s�ea. (srenewre smi rwe) 8 ure ame. �e ena p�ace end aue to ure causecs� smma. �sign�eure ana rwe�
<br />` Jay C. Anderson, MD ~ g s
<br />25� DID Tp6ACC USE CONTRIBUTE TO THE DF1tTH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREDI 28b. WAS CONSENT CiRANTED?
<br />� � YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO NotAppUcable 828a Is NO ❑ YES ❑ NO
<br />2 E, LE AN C TIFlER P SIC , , O S P IAN A (Type or r�
<br />Jay C. Mderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />288. REGISTRAR'S SIGNATURE �+ 28b. OATE FlLED BY REGISTRAR (Mo„ Day, Yr.)
<br />August 11, 2011
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