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<br />STATE OF NEBRASKr4
<br />WHEN THIS COPY CARR/ES THE f�i4/SED SEAL OFTHE NEBRASKA HEA
<br />SYSTEM, IT CERTIFIt�S THE BELOW TQ BE A TAUE COPY OF THE ORlpl
<br />THE NESRASKA HEALTH AND HUMAN SEI�V/CES SYSTEM, VITAL S�A�
<br />THE t EGAL DEPOSITORY FOR VI,TAL RECORDS.
<br />DATE OF 1SSflANCE . � �
<br />� AuG 3 a 2aos � 012 0 7'� 3 2 �$:
<br />L/NCOLN N�B�s� . 21� � 7 0 0 4 S 2 H �
<br />�`��'� :�i�120'7732
<br />TH`ANDH�eI'SERVICES
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<br />CERTIFI�ATE OF DEATH
<br />�`i �:I 1. DECEDENT'S-NAME (Firet, Middle, Last, 9uffix) 2. SEX 3.DATEOFDEATH (Mo.,Day,
<br />„���� Harl.an Dean Sorensen Male August 23, 2
<br />r 4. CITY AND 3TATE OR TfRHITORY, OR FOREI�N CDUNTRY OF BIRTH fie. AQE-Lsat Birthday 5b. UPIDER 1 YEAA 60. UNDEA 1 DAY 8. DATE OF BIRTH (Mo., Day, Yf.)
<br />t���� (Yra.) MOS. DAY3 HOURS MINS.
<br />t'2 ���t Dannevirke, Nebraska 73 June 9, 1933
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<br />�b. 7.SOCIAL&ECURITYNUMBER Ba.pLACEOFDEATH '
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<br />�' �' yOSPITAL: ❑ Inpapenl � 0 NursingHomalLTC ❑HoeplceFeclitty
<br />507-34-5274
<br />Riv.F� f� ' _
<br />;° ' Bb. FACILITY-NAME pf not Inatltutinn, glve atreet and namber) ❑ ER/Outpatient �I DeCedenYeHome
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<br />�'� 908 South Stuhr Road
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<br />'� � ❑ ooa ❑ mnertsv�dry)
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<br />t �: ; i 6aCITYOATOWNOFDEATH (IncludeZlpCOde) 8d.00UN1Y0FDEATH
<br />`k " Grand Island Hall
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<br />i t: BaRESIDENCE-STpTE - Bh.WUMY 9c.CITY0AT0VJN
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<br />;;�r� Nebraska. He.11 Grand Island
<br />Yi'� �, 8d BTREETAND NUMBEfl 8e. APT. NO 8L 21P CODE Bg. INS�OE GITY LlMCf3
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<br />��; 9 8 S uth Stuhr Road 68801 � YES ❑ No
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<br />,! �,, 10a. MAHPlAL STATU3 AT TIME OF DEATH �i+iartied O Never Mertied 10b. NAME OF SPOU9E (Flrat, Middle, Lesf, Sufi(x) II wile, glve meiden name.
<br />y 3�. 1�;� � � '; �•.� .. , �� ',
<br />u Q Manisd, bm seperaled O Wtdowed ❑ Dlvorced O Unlmown
<br />y � Shirleq Holmes
<br />j'�'�p�,",� 1 L FA7HER'S-NAME (Fliel, Middle, Lest, 9ulfix) 72. MOTHER'S•NAME (Flrat, Mlddie, Malden Sumama)
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<br />}���; Oswald' Sorensen Elsie Rasmussen
<br />"�f �; 13. EYEH IN U.3. ARMED FORCE31 Oive detea ot service H yea. 14a. INFORMANT-NA 14b. RELATIONSHIP TO DECEDENT
<br />� y �� � � �orensen
<br />''�a�! (vee,no,orun�.�g 3/25/52-12/4/53 Shirley�- . Wife
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<br />� r` 1b.METHODOF0ISPOSITION 1Ba.EMO ER•810NATURE 1fib.UGENSENO. 16c.DATE.�Mo.,Day,Yr.)
<br />, �F � �.���d�. R. o�.�.tta�uc�$" 1143
<br />�Burlal ❑Donellon
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<br />fi�!, ❑Cremeilon ❑Enrombment 18d.CEMETERY,CREMATORYOROTHEFILOCA710N CITY/TOWN 9TATE
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<br />y� � ❑Ramov� ❑oinar�sP�ciry� Westlawn Memorial Park Cemetery, Gran.d Island, NEbraska
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<br />'' :� 17aFUNERALHOMENAMEANOMAILINpADDRES3 (SUeet;Cityorlbwn,Stete) 17b.21pCode
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<br />;;�.;.;, Lit�ingston-Sondezmann funeral Home, 6Q1 No. Webb Rd., Grand Island NE 68803
<br />��1 � � `��: ,,� � ` ,�: J4�JS��a R' p�p7W Se�;*'1 s�� �ior�s n,���:� �,, p �"$� '� � r ��:� r ,
<br />.t .y r ._f�'�,�, .�� � �, ,kv ..� '!' F.- , -'.s 4 L . .k�,
<br />t� � i& PART 1. Enter the �haln ot evaMa•-diseasea, fnJuries, ar compllcaUona-thet dtrectly ceuaed Ihe dealt�. DO NOT e�rter terminel eventa auch ea cardlao erresb � APPROXIMATE INTEFtVAL
<br />; reaphatory ertest, or venirlculer IWMUetlon withoui ahowing the eUalcgy. 00 NOT ABBREVIATE. Enter onty one cauae on a Me. Add addillonel Iinea N necesaery. �
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<br />� � IMdEEDIpTECAUSE: � �ettodeeli�
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<br />t� �� �O� �� DUE T0, OR AS A CON9EOUENCE OF: I onaet to death
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<br />4 ,.J �9uantlaf{yliatcondNfmis,$ �� I
<br />'� =� mry,leadiiretotheceusellated DUETO,ORASAC�NSEQUENGEOF. I misettodeeih
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<br />r =' ; ; FmertlteUlmERLYW�CAUSE �
<br />a,h ,% (dlseaseoriMurythetlnitieted (°� i
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<br />��@��� ���� DUE TO, Op AS A CON9EOUENCE OF: - �� � � � onset to deaih
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<br />5 +`� 18. PART O.DTHER SI6N�FICANT CONDITIONS-Cortdidoire conhibul(ng to the death bul not reaulting In the und9rfying cauae given In PAR71. �WA3 MEDICAL EXAAdINER
<br />� OR CORONEp CONTpCTED9
<br />+ ";s �,� ❑ YE3 NO
<br />„� L '� 20.IFFEMALE: �A.MA NEROFDEATH 21b.IFTRANSPORTATIONINJURY 9�e.WABANAUTOPSYPERFOiiMED9
<br />\ t ' i;' ❑ Notpregneniw(thinpasiyear �Netural ❑Homldde ❑�rro�� p YES �P10
<br />?;. `� 0 PregnaM et Ume ol deat� ❑ pccident0 Pending Inveatigadan � P�nger "
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<br />"F. R ;y CI Not pregnant; 6ut pregrtant withtn A2 deys o1 death O Sulolde ❑ Could not be determined n P��� 21d. WERE AUTOPBY FINDIN08AVAILABLE TO
<br />s�t� �� � � ❑rnher($Pe�v)
<br />7;,p jr ❑Notp�egn8rtt.bUlpregnelit43deyatolyeprbetofBde9tl1� COMPLETECAUSEOFDENH7 �
<br />! O Unknown fl pregnant wtlhin the past yeat ❑ YEB ❑ NO '
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<br />22a.ppTE OF INJURY fMa„ Oa�YiJ _ 22b. TIME OF I�Y_- - PLAGE (1F_IQI.AIH1U41 homa,-tum, sireN: txNnry �.ronatn�clicnatie,.eto.{Specig)-- -_-- �'- -
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<br />'I�t?;� ?2d,IDlJUR`7ATWOR9C7 2Ee.DESCRIBEHOWINJllRYOCCURRED
<br />� '�� ❑ YfiS ❑ NO
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<br />° `y ti 221•LOQATIONOFINJURY�8TAE6T8NUMBER,'APT.NO. CfIYlfOWN 8T/QE ZIPCODE
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<br />F ��, r� 23a. DATE OF OEATH (Ma, Dey, Yc) 24e. DATE SI4NED (Mo., Day,Yc) • 2Ab.TIME OF DEATH
<br />�,, }�'� ' Au ust 23, 2006 ,�� m
<br />��,�+��� '2�[b N Mo., c) py � ,, �c.17M6pFDEATH �,� 24o.PRONOUNCEDDEAD(Mo.,Dey,Yr.) 2Ad.TIMEPRONOUNCEDDEAD
<br />�� ,� �Z ��T L J L.�ti.XJ 1 Q• 10 te ana p�ace �� a 2ae. on mabasl . m
<br />�� � To t best of _kno�l;d de (��� e an TI1Ie )� g �� a M exeminatton enNorfivestigeNpn,Jo my apinlon deaih accuned at
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<br />f�� ���Q � a to the se s ret�Q. .� �$ the time dete end place and due to the cauae(s) etate4, (3lgnature ertd TiUe )♦
<br />a . �"' $ �!` f�,� � /`� i� ¢ - - -
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<br />� i;�1� J(5.DIDTOBACCOUSECOMRIBUTE70THEDEATH9. 2 ,HA90ROANORTIS3UEpONAT10NBEENCONSIDERED7 •?�QWABCONSENTQRANTE04
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<br />M 1. k �4 0 YE$ NO D PROBABLY ❑ UNKNOWN , ❑ YE8 ❑ 0 Not Appllcabia lt 28a is NO -0 YE9 ❑ NO
<br />�{ �, 27.NAME,TITLEANDADDRE930FCERTIFl�H PHYSIOIAN,CaRONER'SPHYSICUINORCOUNTYA ORNE'� o�Prir�
<br />r{M,�,' Dr. Donald W3r�h, W. �aidley Avenue, Grand Is�and, KE 68803
<br />N �:�.
<br />28e.RE01STRAW3SIqNATURE 28b.DATEFILEDBYRE0ISTRAR (Mo.,Day,Yr.)
<br />AUG 2 � 2006
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