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STATEOFNEBRASKA 2Q12Q5035
<br />WH�N THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND .. MAN SERVICES, Tf CERTIFIES
<br />� �� ., ._. .
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE IVEBRASKAl�EPA�TMEAFT;QF MEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL .R�Ct7RDs� �� ;°� f
<br />Y �1
<br />DATE OF ISSUANCE �/%����� Zl' t � •��`��� �� , t
<br />� q ST�I NCEY S, C��E� '`" � �
<br />Y"�D �, � 2o It� ASSrSTANT �T�,IT� R. ��.�S,T/2Ald r,
<br />bEPA�2�ME11.��'� aF' l-I�AC�`H, %JIVD '; �
<br />LiNCOLN, NEBRASKA _ _ _ ___ _ HUMAI�I SER{�I�ES_ -�
<br />. y 1 �, i � S , ."
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES �� i� bL `�" � f �;�'
<br />�_�RTI�1(_ATG [1� 11FAT41 �`'� � ��:��" a�
<br />Patricia L Peterson
<br />4. CITY AND STATE OR TERRITORY, OR �REItiN COUNTRY OF BtRTH
<br />Blue Hill, Nebraska
<br />7. SOCULL SECURI7Y NUNBER
<br />8b. FACIUTY-NAAAE (H not Instltutlon. 9IvQ street mM mrtnber) '. ,.
<br />Mary Lanning Memordal Hospital
<br />sc. cmr oR rawr� oP oea►t� �u�cmaa ap coaa�
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<br />�7
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<br />8a RE8IDENCE-STATE s�. coun�Tr
<br />Nebraska Keamey
<br />ea eta�r auc eueeser�
<br />140 W. Hawthome
<br />70m. WIRITAL STATU9 AT 77(d8 OP DPATH ❑!lartiad � Nevar �dm
<br />,� blerried, but saperated � Wldowed ❑ Oivmead ❑ Unlmm�m
<br />11, FATHER'&NAALB (First, tdidtU& Lest, Su1�c)
<br />a.ar.x n.ul'+ic�ruewm�lmo.�yef�sr.�:; � .
<br />Female Jan . 22. � 291 b
<br />AOE-Last Birthday Bb. UNDER 1 YFJ1R Bc. UNDER 1 DAY 8. OATE OF BIRTH (lAa, Day, Yr.)
<br />(Yra) MO& DAYB HOUR$ dItNB.
<br />81 November 8,1828
<br />Ba. PLACE OF DRATH
<br />HOSPRAL: � InpaUeM OTHER: ❑ Nmsing Hcrr�1LTC � Hospee FaclOry
<br />❑ ERIOWpadeM � �denfs Home
<br />❑ �A ❑ �(s�s+l
<br />ea. couNrr oF o�►n+
<br />Adams
<br />9a CITf OR TOWN
<br />I ee. arr. Na I 9L LP COOE
<br />88959
<br />70b. NAHIE OF SPOUSE (Fl�sf, tAlddle, Lasf, Sufliz� If aife, plre malden na�rre.
<br />Bg. INSIDE GTY UMITS
<br />� Yas � No
<br />12 dIOTHER'S-NA6IE (FLst, AAlddle, AAalden S�rtname)
<br />13. EVER IN U.B. ARAAED FORCES? GWe detea of mniea If Yea 14e. INFORMANT-Nf►YE
<br />ne�, No, m unic� N Ma Peterson
<br />1& mE7HOD OF WSPOSI710N 18a EMBALI�ERSI TURE
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<br />❑cremetion ❑6�anemma
<br />❑�. ❑�„ 18d. CEML'tERY, CREAANTORY OR OTHER IOCATION
<br />Minden Cemetery
<br />77a FUNERAL HOleH NAAAE AND MNLINO ADDRESS (Street, Ctty or Torm, 8ffite)
<br />Layton Funeral Home, 336 N. Nebraska Ave., Minden, Nebraska
<br />CAUSE OF
<br />ro.aueronmreee. «�.�mrmmun v�naae�ae�. oonrorneeF
<br />� IAlAAEDIAIE CAUSE:
<br />��xeeenwre caus� �neu 1
<br />� ���.eaw�re .� �.z �, n i r A �}•t, ; �
<br />DU@ TO, OR A8 A CON8EQUENCE OF:
<br />s��eeny u� ��. u b) s�' i z... r r S
<br />�n� ieamng w ene a� q�d
<br />°� ��� a ' WE TO, OR AS A CONSEQUENCE OF:
<br />emer a�e uiuuea�nNO cause a! �� v tL �
<br />a
<br />'� ��8B810 O� �fl� �Iffi �f{BEBf�
<br />y�e eve� resWUt�g In deaN� DU8 TO, OR A8 A CON8EGUENCE OF:
<br />1�48T
<br />18b. LICEN88 NO.
<br />CITYf�CNfN
<br />Minden
<br />aro cewa m• mm. aaa aa�a�u mrs a�-
<br />,�cr�t �,'�"'
<br />d)
<br />18. PART LL OTHER SI6NIFlCANT CONDITIONS�Camd(floru aonMbuting to tlre d� 6ut �rot reauidng in the wderiying cauae gWen In PART L
<br />u �ro
<br />1�f. RELATIONSFpP TO DECEDENT
<br />1Be. DAIE (Mc.. �aY. Yr.)
<br />January 25, 2010
<br />STATE
<br />Nebraska
<br />176. ap Ca�
<br />68959
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<br />� otnettodesB�
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<br />� /'h 1 yt �.�' S
<br />1 amet to death
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<br />; 7�Iw�
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<br />i or�t to death
<br />� �r .,^
<br />,
<br />� v�V y�s
<br />1 �
<br />1 olreet to deafh
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<br />18. WA8 NEDICAL EIWMINER
<br />OR CORONER CONTAC'IBD?
<br />❑ � � NO
<br />W �. � FEAAALE: 21a AAANNER OF DEA7H 21b. IF 7RAN8PORTATION INJtI 21a WAS AN AUTOPSY PERFORlLBD?
<br />F C�woe n���.�rn cas� r�r [3'� ❑ aamuuao �� ❑ rES C9'�o
<br />� ❑P.�e � e� a aean, ❑ aowa�rc [] Pm,m�re �s�� ❑ �ser
<br />v a�a. weeE auTOasr Fwuuaos avau►e�.e
<br />❑Not �x �nrt �� as a�re m aea� ❑ su�m� ❑ cowa �we � aa�mi�rea ❑ rea� ro coeeP�ere cause oF oeaniz
<br />.�' ❑ Not pregnan; bdd P+�ant 43 daYe to 1 Y�►before daath ❑ ou� �s�r1 ❑ vES ❑ No
<br />� ❑ Unknown N pregnarrt wNt�in tlre peat year
<br />a
<br />E 22a. DA7E OF WJURY (m0. �9Y. Yr.) 7Zb.'IIiAE OF INJURY 22e. PLACE OF INJURY�At hrnm� Tam�, strflat. �c�ry. oi6ee builtYng, eamWa6on dte. ete. (SP��U)
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<br />. ._ . _ . --� ---- --�- - -- -� - --- ------- --- -
<br />,� ----� --- -- -. . ._ _ . - -' - -'------
<br />O 22d INJURY AT WORK7 72a DESCRIBE HOYY IN,FURY OCCURRED
<br />F' ❑ YES ❑ NO
<br />72f, LOCATION OF INJURY - STREET 8 pIUNBER, APT. NO. CRYROWN BTATE 8p CppE
<br />23a DATE OF DFA (AAo., DaY YrJ ]Aa. OAtE SI�NED (AAm. DaY. Yr.) ?A6.7IAIE OP DPA?H
<br />3�� /�g f /� ��� m
<br />� 236. DATE SIONm (AEO., Day, Yr.) 23e.'IIEAB OF DPA7F1 �� O� 20¢, pRpNOUNCED DEAD (lAo., Day, Yr.) 2Cd TItAE PRONOUNCED DFAD
<br />¢� a��f l aa�o ii y3 e� adQ� ,
<br />� o E g o , m
<br />� 23d. To ere 6�t W mY knarled8e. �ath aawrred at 9�e eme, date mM pia� � W� ?Aa On tho b�is ot e�ninmian �Na Immtigavan, in my op�don dea8i oa�med
<br />mm tlue m e) slatea. (St�rte md'11He1 .� Z at the tlme, data mal qaes end dua to the �use(e) s�ed. (Signawre and Tltle)
<br />o � Op
<br />F� � ��, Fd•��
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<br />0
<br />28. DID TOBAtxO USE CONTRI6UTE Tp'IHE DEATH9. 28a H0.8 OROAN OR TI38UH DQNATION BEEN CONSIDERED? �b. WA9 CONSENT (4RAN'(Ep7
<br />❑ YES � NO ❑ PR08ABLY ❑ UNIQd01NN ❑ YE8 � NO NotApp�cabie BZBaIs NO ❑ YE8 ❑ NO
<br />D. NANE. 71TLE AND ADDREBS OF CERT(F1ER (PNYBtC1AN. PFfl'SIGAN A8319TANT, CORONQt'9 PHY8ICUW OR COUMY ATTORNCY) I�YPo ��)
<br />Lorraine Edwards, D., 2727 W. nd St., �F'340, Hastin s, NE 68901
<br />28a. REti1STRAR'S SIGNATURE �Bb. DA7E FlLED BY REGISTRAR (AAu.. GeY. Yr.)
<br />P FEB i o 2u�o
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