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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT.OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V77'AL RECDRDS. `"- �, ,,
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<br />DATE OF ISSUANCE ' •�: �
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<br />06/04/2012 i � STAN��';s, � cQ�i��R � 4, �, _ „ �: „
<br />2 O � (� � � � � 1J4 DEP�'R�l�'I�AIT A F � H AN� � , , � y
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<br />LINCOLN, NEBRASKA HUI�LIAF�SER E , �, ,,,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC,ES�, '. ;,� � n,� Qo �
<br />CERTIFICATE OF DEATH r,, �•..�' �' .: �rP"°'
<br />7. 4ECEDENT$•NAME (FI�St� Middle� L.aet� Suffbt) 2� SIX `;� e`�� 3., � A'I� � �`Ii,�MpY,_ Dey� Yr.)
<br />Elnore Marie Lundell Female '� � ay'26; 2Q8�'� `�
<br />4. ITY AND 3TATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 3a. AGE • Last Blrthday b. UNDER 7 YEAR 8c. UNDER 1 DA �; .8 A�L� OF BI TFh(Mo., Day, Yr.)
<br />(Y�•) MOS. DAYS HOURS MINS. ��` .,' � � w V �
<br />Faribault, Minnesota 79 F'August 9, 1932
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />t}��3428,Q,� HOSPITAL � InpaUeM OTHER ❑ Nursirtg Home1LTC � Hosplce Factlity
<br />8b: FACILITY•NAME pf not Irretltutlon, glve street and numbar) � ER/Outpatlerrt ❑ DecedeM's Home
<br />�
<br />� Sa(nt Francls Medical Center ❑ �A ❑ �'' �s��'1
<br />c�
<br />� Be: CITY OR TOWN OF DEATH p�rclude Zip Code) Sd. COUNTY OF DEATH
<br />c Grand Island 68803 Hall
<br />� 8a. RESIDENCESTATE 8b. COUNTY 8c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />� 9d. STREET AND NUMBER . APT. NO. 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />�' 645 Joehnck SG 68801 � r�s ❑ No
<br />$ 70a. MARITAL STATUS AT TIME OF DEATH � Marrted ❑ Naver Marrled 10b. NAME OF SPOUSE (Flret, Mlddle, Last, Suftix) H wlfe, glve malden �me
<br />� p r��ea but separated p unaoWaa p on,o.�aa ❑ u�o�,� Marlan �undell
<br />m
<br />� 11. FATHER'3•NAME (Flrst, Middle, Laet, SuffGc) 12. MOTHER'8-NAME (FIrel, Mlddle, Maldan Surrmme)
<br />Fred SchmHz Edith Ray
<br />E 13. EVER IN U.S. ARMED FORCES? Give dates oi service If Y�. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ �res, n►o, or unic.) No Marlan Lundell Spouse
<br />� 1S: METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 16b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />f ? 0 sur�a� ❑ uonaeon Not Embatmed May 29, 2012
<br />� CrertaUon ❑ Entombme�rt �ed. CEMETERY, CREMATORY OR OTHER IOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Specify)
<br />Central Nebraska Crematlon Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, SYate) 17b. Zip Code
<br />All Fafths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />AUSE OF DEATH See nstructlons and exam les
<br />1B. PART 4 EMer the ehaln M eveMe--0iaeasea, InJurlea, or eomp�wtlonrihat NrectlY aaused the death. DO NOT enter terminal eve�rte such as carmac arreat, ; APPROXIMATE INTERVAL
<br />reaplratory ertest, or veMrlwlar flbrlliffiton wltliout showin8 the e8otogy. DO NOT ABBREVIATE. E�rter onty orte cause on a One. Add addWo�ml qnea H�ry. �
<br />IMMEDIATE CAUSE: ; onaet to death
<br />IMMEDIATE CAUSE (Flnal a) Advanced /�qe 6 80 Years
<br />dlsease or condition resuiting ;
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death
<br />SequeMtaUy Ilet condWone, lf b)
<br />enY. �eading w ehe cauae I�ted i
<br />'� �� DUE TO, OR AS A CONSEQUENCE OF: � o�et to death
<br />Eneertt�e uwueranNCS cnuse �) i
<br />(dieease or InJury tF�at IniUatea '
<br />Ure eveMe resulU� In deatn) DUE TO, OR AS A CONSEQUENCE OF: � o�et to death
<br />� d) _
<br />18. PART It. OTHER SIGNIFlCANT CONDITIONS-Comiitlo�re corrtribufJng to the death but not resultl� In the underlying cauae gWen in PART I. 18. WAS MEDICAL EXAMINER
<br />Coronary Artery Disease, Atrial Fibrillatlon, Diabetes Mellftus oR CORONER CoN7ACTEO�
<br />� ❑ ves � nto
<br />W 20. IF FENW.E: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED7
<br />� � Not P�B� wtthln peat year � Natural � HoMclde � Driver/Operator �� � NO
<br />� Q Pte9nant et tlma oT death � AccltleM � Pendln8 imeaUB�on ❑��neer
<br />� Not pregnaM, but pregnant withln 42 days M death g��tle Coutd not be determhred � P��" 27d. WERE AUTOPSY FlNDING9 AVAILABLE
<br />'� � Not pree�+k but pregnaM 49 aays m 1 year beTO�e death ❑ ❑ � pthe� �gpB���y) TO COMPLETE CAUSE OF DEATHI
<br />� � Unlmown H pregnent withln Ne past year ❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURY�At home, farm, street, factory, office bullding, corre6ucdon eke, etc. (Specify)
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<br />� 22d. (NJURY AT WORK7 22e. DESCRIBE HOW INJURY OCCURRED
<br />I�-
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & 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 />,� May 26, 2012 S �
<br />� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ��� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� Z Ma 29, 2012 10:26 AM �<�
<br />�� � . To the bes! M my Imowietlge. death occurred ffi tire tlnre, tlffie and place $� � 24e. On the basis MexemUmtlon antl/or ImeaflgaUan. in my opinion death occurteE et
<br />o � end due to Ure ceuse(s) atated. (81 8naWre end Title) � z� the Ume. tlate and place and due to the cauae le) slated. (SlBrmd�re end Tltle)
<br />~ David R. Colan, MD ~ g s
<br />25: DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED9
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YE9 � NO Not Applicable H 28a Is NO ❑ YES ❑ NO
<br />2. E, T LE D ADDRE F CERTIF R P I T, R SIC R CO N ORNE1n ype or Prlrrt
<br />Dav(d R. Colan, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE �` 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />May 30, 2012
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