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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 />