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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH Afitfl NUMAN'�YRVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASlE;4°DC�P�IRaI'V�1�NT�:OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR IILTAC;I��'GC�R�S.' �•.. ",
<br />7 �
<br />, � / J � �.
<br />DATE OF ISSUANCE �f � �...' L� . ','
<br />SrA'N,L�' S. C�(QRER,, - ,, `, , .
<br />04/18/2011 ASSIS�C'AMT �"qT�' _�EG�S�RAR:'' '. ,
<br />bEPARs�n'IENT OF. HEALTH AND , -
<br />LINCOLN, NEBRASKA HUM�4A���S�R1I,�CES r ;, ��'�> -`
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC�S C E �` '� �� z•� .y� � �''
<br />K �. � •.. _�11 01172
<br />�trc� irwP►i � �r urr+►i n � S,: ,�,�, ,�
<br />7. DECEDENTS•NAME (Flret, Middle, Last, SufNc) 2. SIX "�, � 3, DATE OF DEATH (Mo., Day, Yr.)
<br />Klrk Lee Perrelet Male �Aprll 7, 2011
<br />4. CITY AND STA7E OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AOE - Last BlRhday b. UNDER 1 YEAR 5e. UNDER 1 DAY e. DATE OF BIRTH (MO., Day, Yr.)
<br />(Yre•) MOS. DAYS HOURS MINS.
<br />Omaha, Nebraska 60 December 18, 1950
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />508-6&1254 OSH PR L� irtpatlerd O� ❑ Nursing Home/LTC � Hosplce Faeltlty
<br />8b. FACILITY•NAME pf rrot I�titutlon, give atreet and number) � ER/OutpatlerR ❑ DeeedenCs Home
<br />�
<br />� Saint Francis Medical Center ❑ �A ❑ � (sneCKrl
<br />c�
<br />� 8c. C17Y OR TOWN OF DEATH pncluda 21p Code) Sd. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 9a. RESIDENCESTATE 9b. COUNTY 8c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL 8d. STREET AND NUMBER 8e. APT. NO. 8i. ZIP CODE 8g. INSIDE CITY LINOTS
<br />307 S S camore 68801 ��s ❑ No
<br />� 70a. MARITAL STATUS AT TIME OF DEATH � Marrled ❑ Never Married 10b. NAME OF SPOUSE (Firat, Mlddle, Last, SuRix) N wtie, gWe maiden mame
<br />� ❑ ma..�ea, n�n $a��ae� ❑ �nnaow0a ❑ nrvo►�a ❑ u�no� Georgia Marie Harms
<br />� 11. FATHER'3-NAME (Flrat, Middle, Last, Suffbc) 12. MOTHER'S•NAME (Flrst, Middle, Maiden Sumame)
<br />m Tell Henry Perrelet Franc:es Leona Gunsolley
<br />°' 73. EVER IN U.S. ARMED FORCEST Give dates of aervlce ff Yea. 14a. MFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />$ �res, No, or uNc.� No Georgia Marie Perrelet Wife
<br />� 1S. METHOD OF DISPOSiTION 18a. EMBALMERSIGNATURE 78b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F ? ❑ BuHal ❑ Donatlon
<br />Not Embalmed Aprll 9, 2011
<br />� CremaUon Q EntombmeM �8d. CEMEfERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />❑ Removai ❑ Other (Speeliy) Central Nebraska Crematlon Services Gibbon Nebraska
<br />17a. FUNERAI HOME NAME AND MAILING ADDRESS (Streef, Clty or Town, State) 17b. Zlp Code
<br />AII Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUS OF DEATH See Instructions and exam les
<br />1B. PART L Frrter the chaln o_ f e�tiilseaees, InJurles, or complleaGana-that tlireGy caused the death. DO NOT eMer tertninal eveMe auch es cardiac arreet, ; APPROXIMATE INTERVAL
<br />reaplratory arrest, or veMriwlar ftbriilatlon rrtti�out ahowing the etlWogy. DO NOT ABBREVINTE. E�rter onty one cause on e Il��re. Add addfdonal Ilnes H neceseary. :
<br />IMIV�DIATE CAUSE: ; onset to death
<br />nan�owrECnusE� a) End Stage Chronic Obstructive Puimonary Disease With Respfratory Failure ; One Week
<br />disease or condlHon reautting '
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: ; ortset to death
<br />Sa4�enNeOY Ilet eonditlona It b)
<br />eny.l�dlnB to th9 cauee Ilsied
<br />on Il�re a DUH TO, OR AS A CONSEQUENCE OF: � orreet W death
<br />EMertlte UNDERLYIN6 CAUSE C ) �
<br />(disease or InJury that InlUatetl �
<br />���"�U"a m�'� DUE TO, OR AS A CONSEQUENCE OF: � ot�et to death
<br />� d) '
<br />18. PART p. OTHER SIGNIFlCANT CONDITIONS�o�itlona contrlbuting to the death but not resuitlng In the underiyi� cause gfven In PART 1. 78. WAS MEDICAL IXAtY�NER
<br />OR CORONER CONTACTED9
<br />� ❑ YES � NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />� � NM P�e9�t Mthln �st Yeer � Nafural � Homiclde � DrivedOperatur � YES � NO
<br />v ❑ PBe�M m w� �r a�n � n�wa�rc � PerMInB ImesdBeMOn ❑ a��$e�
<br />� Not pregnant, but pregnem wiNUn 42 deye af death gulcide coaa na ue aeeemu�rea � Pedeatrl8" 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />'� � Not preg�mnt, but pregttant 43 daye to 1 year before tleath � � � p�� �sp� TO COMPLETE CAUSE OF DEATH?
<br />� ❑ Un�mown if P�BnaM withln tlee P� Year ❑ YES ❑ NO
<br />°' 22a. DATE OF INJURY (MO., Day, Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURYd►t home, farm, street, factory, offlee butlding, cor�struction sfte, ete. (Specify)
<br />E
<br />$
<br />.� 22d. INJURY AT WORK7 22e. DESCRIBE HOW INJURY OCCURRED
<br />H
<br />❑ YES ❑ NO
<br />22F. LOCATION OF INJURY • 9TREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />S � April 7, 2011 � � �
<br />� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ��} 24e. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />$� o A rfl 8, 2011 01:10 PM � 4<�
<br />. To She best of my Imowletl9e. death occurted et the tl�. deta end ptace $ O
<br />T4e. On the baele oi eYaminetlon and/or Imeatlgatlon, in my opinion deafh occurted at
<br />$� and due tn the eause(s) efated• (SlgnaNre and TRle) � Ute time. date antl place end dua to tlee eause(s) sfated. (Signature end Title)
<br />~� Richard Fruehling, MD ~ g s
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATHT 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED9
<br />� YES ❑ NO ❑ PROBABLY ❑ UNIWOWN ❑ YES � NO NotApplieable B28a la NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADD O E TIFI R(P Y31 , HYSIC 1 , COR NER S PHYSI R O N A RNE1� (Type or Prlrrt)
<br />Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE � 28b. DATE FlLED BY REGISTRAR (Mo, Day, Yr.)
<br />April 11, 2011
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