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STATE OF NEBRASKA -: � Q�. � O,"1�:9 5�
<br />�AN SERVICES,1'� CERTIFIES
<br />;l,�Mt t3F HEALTH AND
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HE9L-:�fa! 591l�Q HUI
<br />THE BE�.OW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH TME NEB�A$ �qE �Jh'f�
<br />HUMAN SE�2VICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORX�QI����.�QltL
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<br />DATE OF ISSUANCE ��
<br />� 1� .
<br />07/09/2012 - - $TANL� S. �OQPE
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<br />LINCOLN, NEBRASKA ".>! `�: HUMAN SERDICES : c �; -
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<br />/�� STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SE�tYIC�� f{ �, y Y���' • y �__ �
<br />FUllend�d Arl1T�l��A �Tl� �� �r ��� ■ 12 01384
<br />VGR I lrlV/11 G Vr YGf11 rl � U� " - •-. e �
<br />1. pECEDENTS-NAME (First, Middle, Lasf, SuHbc) 2: SE�C' �[! �•�+ �` �: DATEDF DEATH (Mo, Day, Yr.)
<br />Leslie Brandt Knudsen Mare'' °, t.- ., �. �. April 15, 2012
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 pAY 8. DATE bF BIRTH (Mo., Day, Yr.)
<br />(Y�•) M09. DAYS HOURS MINS.
<br />Pilger, Nebraska 88 April 4, 1924
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />b06-22-4506 IF OSPR L❑ InpatleM OTHER ❑ Nursing Home/LTC � Hospiee Facli(ty
<br />Bb.fACILITY-NAME (B not Instidrtlon, give street am! number) � ER/OutpaUent � Decede�R's Home
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<br />� 3112 Magnolla Ck ❑ DOA ❑ Other(SpeeHy)
<br />� 8c. CITY OR TOWN OF DEATH pnclude Lp Code) 8d. COUNTY OF DEATH
<br />c Grand Island 68803 Hall
<br />� 9a: RESIDENCESTATE 8b. COUNTY 9e. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL 9d. STREET AND NUMBER . APT. NO. 8f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />� �112 Ma notia Ct. 68803 ��s ❑ No
<br />� 10a. MARITAL STATUS /iT TIME OF DEATH � Manied ❑ Never Married 10b. NAME OF SPOUSE (Firet, Middle, Last, SuHi�c) If wHe, give malden reme
<br />€ [] m�maa, b�rt 8.r�►�c�a ❑ wiaowaa p on,o►�a ❑ u�� Dolores Jehorek
<br />m
<br />� 11. FATHER'S•NAME (Flrst, Npddle, Last, Suffbc) 12, MOTHER'S-NAME {Flrst, Mlddle, Nlalden Sumame)
<br />m Chris M Knudsen Ida K Laursen
<br />�' 13. EVER IN US. ARMED FORCES? Gtve datea oT aervice H Yes. 14a. iNFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />S
<br />$ �lles, No, or umc.) Yes 12/21/1944 Dolores Knudsen Spouse
<br />,$ 15. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. UCENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F � Burial ❑ DonaUon
<br />Kevin Wood 1325 April 19, 2012
<br />�] CremaUon Q ErRombmeM �gd. CEMETERY, CRENUITORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removai ❑ ower (speary� Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, Ctty or Town, State) 17b. Zip Code
<br />Livingston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 68803
<br />CAUSE OF DEATH See Instructtons an exam les
<br />1& PART I. EMer the chain ot eveMS--0iseaeea, InJuMea, or compllcaUOns4hat dlrecUy causetl the death. DO NOT eirter terml�l eve� auch as mrdlac arrest, ; APPROXIMATE INTERVAL
<br />respiratory artest, or ve�Micular flbriflaflon without showinp the etlotogy. DO NOT ABBREVIATE. FsOer only o�re eause on a tlne. Add aAtlitlorml Ilnea it neeeeaery.
<br />IMMEDIATE CAUSE: ; orreet to death
<br />ndn+eow� cnuse � a) Heart Attack : Immediate
<br />dl�ease or conmuon resumnp
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />sev�am� n�s �o�amo�, e b) �ronary Disease : Ongoing
<br />e�ry. leadinp ta the cause tletetl ;
<br />an nne a. DUE TO, OR AS A CONSEGUENCB OF: � onset to death
<br />Enter the UNDERLYINO CAUSE �) :
<br />(dlaease ar InJury that IniUated
<br />the everrte reeuldng In death) DUE TO, OR AS A CONSEQUENCE OF: : o�et to death
<br />LA9T ,11 i
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<br />18. PART U. OTHER SIGNIFlCANT CONDfTION3-CorMHio� conMbutlng to the death but �rot r�ulUng In the undertying eause given In PART 1. 78. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED4
<br />� ❑ YES � NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJU 21a WAS AN AUTOPSY PERFORMED?
<br />LL
<br />� � NM preB�M within P� Y�+ ��w� � Homlclde � om�ro
<br />v [] a�e�m � u� or a�u, � a�aa.M � ae�ai�e imreaneanon ❑ r�"eB. ��s � No
<br />T Q Not prepnant, but prepnant vvrthln 42 Aaye ot desth eulWde Coum nM be tlemrmi�retl � P��" 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />'� � Not ptepnaM, but p�epna�K 4S daye W 1 year bB(arB death � � � p�� �g TO COMPLETE CAUSE OF DEATH?
<br />Q Unlmown it Pre9�a�rt wtthin Uce P� Y�
<br />❑ ves ❑ NO
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, Tarm, street, factory, offlce bullding, constructlon aite, etc. (Sp�tfy)
<br />�
<br />� 22d. INJURY AT WORK? 22e. DESCWBE HOW INJURY OCCURRED
<br />0
<br />E' ❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYlTOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (M1Ao., Day, Yr.) 24b. TIME OF DEATH
<br />B ffi ��� April 17, 2012 Approx. 01:00 AM
<br />�� J 23b. DATE SIGNED (Mo„ Day, Yr.) 23c. TIME OF DEATH ���} 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />$„ o �� o A ril 15, 2012 10:35 AM
<br />3tl. To the beat oT my Imowledpe, deafh oecurteA at the tlme, date and plece $ 24e, pn the basls M examinatlon analor InvesfiBaGun, in my opinlon tleath occurtetl at
<br />�� antl tlue W the cause(s) afa[ed. (Signature a�M TIGe) $ the tlme. date and place and tlue to the cauae(e) eteted. (Sipnadire and Tftle)
<br />~ ~ g� Robert Casholli, Hall Deputy County Attomey
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH4 26a. HAS ORGAN OR TISSUE �NATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTEDT
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO NotAppllcable H26a Is NO ❑ YES ❑ NO
<br />27. NAME, ITLE F TIFIER (PHY 1 IAN, 1 AN , R P Y UNTY A ype or rrt)
<br />Robert Cashoili, Hall Deputy County Attomey, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />28a. REGISTRAR'S SIGNATURE � �' 28b. DATE FlLED BY REGISTRAR (Mo, Day, Yr.)
<br />April 19, 2012
<br />nded
<br />07/09/2012 Items 10b & 14a first name
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