STATE OF NEBRASKA �
<br />WHEN THIS COPY CARRIES THE R,4ISED SEAL OF THE NEBRASKA DEPARTMENT OF HE9L'TFf,4�AFt7
<br />THE BELOW TO BE A TRU� COPY OF THE ORIGINAL RECORD ON FILE WITH �THE NEBRA�f�4 ,�',E,�?
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY F(JR f�7T L REC
<br />.�, � "`w
<br />DATE OF ISSUANCE ' v
<br />� 01 �` a� 0 4 3� S� �.��
<br />SEP 0 7 2011 - �
<br />LINCOLN,. NEBRASKA- w_ , �
<br />pF
<br />y;aiv ���vrc�s IT CERTIFIES
<br />MEd I�;F O� 1-IEALTI-1 AND
<br />� '`''F'. ' *
<br />C���:�
<br />,,
<br />� ,
<br />,.
<br />=R, .� ' , .,. ,
<br />�ftEGISTR�IR � '
<br />EALTH ANq �
<br />STATE OF NEBRA$KA - DEPARTMENT OF HEALTH AND HUMAN SEf}VIGES � i7 ��, r � � ��;� ��
<br />�- CE T IC F D AT . ��°- " �
<br />1. DECBDENi'S-NAME (Flrst, AtWtlle. Lee4 �x) .. •3�, � 2 SEX � : . 3.'DAT� Cp'DEATH (Mo �.Dey:7r.) . .
<br />James Henry Carlson Mate August 27, 2011
<br />d. CITY AND BTATE OR TERRITORY, OR FOAEION COUNTRY OF BIRTH 6a. AOElast BiRhdey Bb. UNDER 7 YEAR 6c. UNDER 10AY 8. Cd7E OF BIRTH (Mo., Day, Yr.)
<br />(Yre.) MOS. DAYS HOURB AAIN8.
<br />Hhll County, Nebraska -� 70 July 1, 1941
<br />7.,�OCIAL SECURITY NUMBER 8a PLACE OF DEATH
<br />� 505-48-5657 �' .HOSarra�: � �nPaueM QTHEB; Q Nuraing Home11.TC � Hosplae FacAltyr �
<br />� . .
<br />9 8p. FACIl.ITY-NAAA6 (M rtot InsHWNon, 9ive atreet arM number) ❑ ERlOutpatlarrc � DecedeM'e Hoina
<br />� Veterans Affairs Medical Center � � °Oa p � s ��
<br />0
<br />� e�. CITY OR TOYVM OF OEA7H prtcfude ZIP Code) 8d. COUN7Y OF DEATH
<br />W Grand Island 68803 H��
<br />Z 9a RESIDENCE-BTATE 8b. COUNTY 9a CITY OR TONM
<br />�
<br />LL �
<br />�, Nebraska Halt Grand Island
<br />y 8d. STREET AND NUMBER -� 8e. APT. NO. 9L ZIP CODE 8g. WSIDE CfIY LIMITB
<br />� 1032 N. Custer Avenue 6 � Y8° ❑"
<br />�
<br />� 10a MARITAL STATUB AT TIEAE OF DEATH � Aderttad ❑ Never dlartied tOb. NAME OF SPOUSB �Fltat; AEidme, Lest, S�Afia) M wHe, 8ive malden n�ne.
<br />Q p ea��+. �nrt �a�cea p wnaawea ❑ owcmea p unwmwn Betty Ann Reimers
<br />�' 11. FATHEIY&NAME (Flrst, M�ddle, Last, SuNBt) 12 MOTHER'&NAME (Flrst, Middle, Malden Bumame)
<br />E
<br />� a � Adrian W Carlson Rufh Ann Eafon
<br />m 13. EVER IN U.S. ARMED FORCES7 Oive detee M service H Yee. 14a INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />O
<br />1 �1fee, No, m unk� Yes 04/13/1964 Be Carlson �fe
<br />16. METHOD OF DISPOSITION 76a EM MER•SIGNATURE 18b. LICENSE NO. 78e. OATE (bto., Dey, Yr.)
<br />�a�� ❑��^�°^ � �, �� ��j�� Au ust31,2011
<br />❑crem.��oo pemomnmom ,
<br />18d. CEM , CREMATdiRY OR ER LOCATION CIiY/TONM $TATE
<br />�� �Remova� ❑Otnm(specHy) . .
<br />Westlawn Memorlal Perk Cemetery Grand Island Nebraska
<br />17a FUNERAL HOME NAME ANU MAILINO ADDRESS (Street, Cliy or Town, Steta� ��' �P �
<br />Apfel Funeral I-lome,1123 W. 2nd,.Grand Island, Nebraska 68801
<br />CAllSE'OF DEATH (See instructions and examplesD
<br />7 PART L FMer the chetn oI erent+. dise�a, InJu�lea, or compOr.�lons.thm Nrectly aeueed 1he Getlh. DD NOT eMerterm6W evarta auch q eartlhe ertee4 - � APPROXIANITE INTERVAL
<br />.,ren2lrstnrv ��rde�. e�� vaMriculer_F.6NRS1ion vui6iout e�owin9 tlro etln�nBf. ��dOT ABBREVIATE. Eemr oNy aro mne oa a Ms AAd adBtlonN qrma iT mcestM�� 1
<br />.� - . IMb1ED1ATECAUSE:� '' ; i , � �\ i anuatiodwcn -
<br />�+ t
<br />IN�MEDIATE CAU8E (Flna� ., " ° � � ,
<br />. t ,
<br />diseaseorcondttlonreaWd� a) C � � ., � __.._
<br />in'tleath) . . � .
<br />DUE T0, OR A8 A CONSEQUENCE OF: � onsat ro death
<br />- �
<br />89quentially Oet comlltlorre, If � '
<br />re b)
<br />u�p� leading to Ute ceuee �ated �
<br />' � a DUE TO, Ott A8 A CONSEQUENCE OF: i°^�t m death
<br />;:s"F ° �
<br />Ehterthe UNb6RLYINO GAUSB �) � '
<br />i
<br />(diseaee or Injury that InlGetad OUE TO, OR A8 A CONSEQUENC OR: �
<br />tha eveMs resuid� In death) �i o�reet to deeth
<br />�
<br />LAST � t
<br />�
<br />d) �
<br />�
<br />18. PART 0. OTHER SI6NIFlCANT CONDI710N3-Comlltlorre coMributing to the death but not resWdng 1� Me untlerlying eauae gfven In PART L 19. WAS 6lEDICAL EXAMINER
<br />ORCORONERCONTACTED7
<br />. ' b c . . . , � ❑ ,�s j� No
<br />� '�O. IF FEMALE: ' 21e. NER OF DEATH 21b. IR TRANSPORTATION 1 RY 21a AN AUTOPSY PERFORMED9
<br />� [� Not pregnant withln past year :'`�,�Vauual ❑ Homloide ❑ DAvedOperator ❑ YE9 NO
<br />W ['�Pregnant at tlme of death QAccldeM ❑ Pemm�g finesd8�on � Paseen88r �d, yygpe AUTOP9Y FlNDINOS AVAILABLE
<br />V � Not pregneM, but pregnaM within 42 daye of death ❑ Sutcida ❑ CoWd rrot be determtned ❑ Pedestrlan TO COEAP AUSE OF OEATH9
<br />.� ONot pregneM, but pregnant 43 deye to 1 yeaz betore death � � ❑�e� ISP��{Y) ❑ res �'J No
<br />� �Unimmxn H pre8narrt withh� the paet year ��
<br />a d
<br />E `�l2a. DATE OF INJURY (Mo., Day, Y�.) 22b. TIAAE OF INJURY 22c. PLACE OF iNJURY-At hama, farm, etree�, teetory, oftice bupding, constructloq site, eto. (Speelfy)
<br />t, .'� m
<br />� 22d INJURYAT WORK? Yle. DESCWBE HOW INJURYOCCURRED
<br />-k n
<br />. _ � v�s o - . - _ . � r - • -- - -, __ _ - - _ .
<br />� --
<br />�2L LOCATION OF INJURY - STREET 6 NUMBER, APT. NO. CITYITOWN STATE aP CODE
<br />�
<br />�� 23a. DATE OF DEATH (Mo., Day, Yr.) ' Z 24a. DATE SIGNED (INo., Day, Yr.) 24b. TICAE OF DEATH
<br />I
<br />�� � ,�'v� m
<br />� ' 756. D SIGNED (Mo., Day, Yr.) 23e. TIME-OF OEATH �.� � O 24c. PRONOUNCED DEAD �mo., Day, Yt.) 24d. TIAAE PRONOUNCE� DEAD �
<br />W} m �Y
<br />E� . 1\ • . m �u�,az m
<br />� a � 23d, b�t M my , death oee et e tinre, dffie aml plaee ���� 24e. On the basls M eamNnatlon mdlor ImeaBgatlon, in my oplNon death oeumed
<br />� U an e ea (Sign tie ,o O O at tha 8rt�, dete and plaee and due m the cauae(e)atated (SlgnaUUe a�M Tltle)
<br />F� � FO .�
<br />U O
<br />�t8. DID TOBACCO US8 CO BUT DEATH7 a HA8 OROAN OR TI88UE DONATION BEHN CONSIOERED9 28b. WA9 CONSENT ORANTED?
<br />�❑ YES ❑ NO BABL bWN ❑ YES NO NoYApplteable H28e ta NO ❑ YES � NO
<br />�7. NpME, TRLE AND ADDRESS OF CERTIFlER (PHYSICIAN, PHYSICIAN ASSISTpNT. CORONE(YS PHYSICUW OR COUNTY A'ITORNEY) (Type or PA�rt)
<br />� . � ' �C � . • � 'c �� ' � C N �
<br />aea. �ois��s s�arwTUaE 28b. DATE FILED BY _!+� z �" ' rr.�
<br />P ' � - ,�.
<br />0
<br />
|