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<br />STATE OF NEBRASKA
<br />WHEN TH/S COPY CARRIES THE RA/SED SEAL OF THE NEBRASKA
<br />` SYSTEM, lT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE Q
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL
<br />THE LEGAL DEPOS/TORY FOR VlTAL RECORDS. '
<br />DATE OF ISSUANCE
<br />JUL 11 2006
<br />UNCOLN, NEBRASKA
<br />�0120�33�;��
<br />q,LtHA 11 Ib�_A_N SE'RVICES
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<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANGE AN[7S ,�a.
<br />CERTIFICATE OF DEATH ��'� " �'�� ��
<br />1. DECEDENT'8-NAME (Flrat, Middle, Laet, Sutflx) 2. SEX 3: DATE OF DEATH (Mo., Oay,Yr.)
<br />Ratherine Fern Christensea gemale July 4, 2006
<br />4. CITY AND STATE OR TERRITORY, OR FOREION COUNTRY OF BIRTH 6e. AOE•Laet B�rthday 6b. UNDER 1 YEAR 6c. UNDER t DAY B. DATE OF BIRTH (Mo., Day,Yr.)
<br />(Yie.) MOS. DAYS HOURS MINS.
<br />Broken Bow, Nebraska 79 October 11, 1926
<br />7. SOCIAL BECURITY NUMBER Ba. PLACE OF OEATH
<br />506-30-3488 HOSPITAL: ❑ Inpetlent � ❑ NureingHome/lTC �}I�piceFactlity
<br />Bb. FAbIUTY-NAME' p}:nol Institutlon,`give atreet and number) ❑ ERlOUtpatient �DecadenYeHome
<br />St. Francis Skilled Care �� p�,��
<br />Bc. GITY ORTOWN OF DEATH (Include Zfp Code) 8d. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />9g. INSIDE CITY LIMIT&
<br />'� YES ❑ NO
<br />Meidan Surname)
<br />13. EVER Ifl U.S. ARMED FORCES7 Oive dates of aervice if yea. 14a. INFORMANT NAME 14b. RELATIONSHIP TO DECEDENT
<br />(Yes,no,orunk.) No Clifford W. Chriatensen Husbaad
<br />15. METHOD OF DISPASITION 18a. EMB ER-SI� A E 18b. LICENSE N0. 18c. DATE (Mo., Day, Yr. )
<br />❑Burlel ❑Donauon �' �,� � I � Julg 6� 2006
<br />�,Crematlon ❑ Eniombment 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑Removel ❑Other(3peclty) Central Nebraska Cremation Service, Gibbon, Nebraska
<br />17a FUNERAL HOME NAME AND MAILINO ADDRE33 (Street, CNy orTawn, Stele) 17b. Zlp Code
<br />Rleine Fuaeral Home, 3213 W North Front St., Graad Ialand, NE 68803
<br />8a. RESIDENCESTATE 86. COUMY 8c. CITY ORTOWN
<br />Nebraska Hall Grand Isla�hd
<br />8d8TREETANDNUCABER Be.APT.NO Bf.Z�PCODE
<br />2429 Pioaeer Blvd. 68801
<br />10a. MARITAL STpTUS ATTIME OF DEATH �Martled ❑ Never Married tOb. NAME OF SPOUSE (Flret, Mlddle, Leat, Sut(Ix) Ii wife, give maMen neme.
<br />❑ Merried, but seperated ❑ Widowed ❑ DlvorcAd ❑ Unknown Clifford W . C11Ti8t8I18eA
<br />11. FATHER'S•NAME (Flrat, Mlddle, Lest, Suffix) 12. MOTHER'8-NAME (Firet, Mlddle,
<br />Charles (I�4II) Carlaad Nelle (1�Il�II) B3.nkley
<br />1& PART I. Enter the chein oi evenls-dlaeases, InJurlea, or oomplicattone-ihet directly caused the death. DO NOT enter terminal evente euch es cerdlec errest NPNh�UJ�IMAI C IN I CFIVAL
<br />I
<br />reaplretory enest, or venUloular Ilbrlllation wilhout ahowing the eUology. DO NOT ABBREVIATE. Enter only one ceuse on e Iine. Add edditlonai Ilnes fl neceaeary. �
<br />IMMEDIATE CAUSE � onset to death
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<br />(e) Qv�.1f�1�1/`L �..A�-ie� GQ,+'�� � �� v � ""
<br />R�7EDIATE CAUSE (Fbml I onaei M death
<br />�m�����8 DUE T0, OR AS A CONSEQUENCE OF:
<br />In death) I
<br />SequeMlally Ilat comlltlona, H ro� � I
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<br />�1'��gt DUETO,ORASACON9E�UENCEOF: I onsettodeath
<br />on Iinea I
<br />Ertter9reUNDERLYPIOCAUSB I
<br />(diseaseorfn)urythatMitiated (°� i
<br />theeuentaresulUngindeath) DUETO,ORA3ACON3E�UENCEOF: � onaetMdeath
<br />IAR� �
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<br />18. PAFlT II.OTHER SIflNIFICANT CONDPfI0N3•Condillone contribuUng to the death 6ut not resuliing In the undertying ceuse given in PART I. 18. WA3 MEDICAL EXAMINER
<br />OFiCORONERCONTACTED4
<br />❑ YE8 NO
<br />20.IFFEMALE: ' 21a.M �ANNEROFDEATH 27b.IFTRAN3PORTATIONINJURY 21c.WA3ANAUTOP3YPERFORMED4
<br />�Notpregnantwithlnpastyear Ji�Neturel ❑Homidde ODrlvedOperetor � YEg �/'O
<br />� ❑ Peasenger f a'TV
<br />❑ Pregnent et ttme of death ❑ Accldent0 Pe�ng Inveatlgetlon
<br />❑Notpregnant,bulpregnantwilhln42daysaideaih ❑Pedeatrlan p�d,yyEREAUTOPBYFlNDINOSAVAILABLETO
<br />❑ Suiclde ❑ CoWd not be determined p Other (Speolfy)
<br />❑ Nai pregnent, but pregnan143 deys to 1}rear betore death COMPLEfE CAUSE OF DEATH?
<br />❑ Unknown II pregnantwBhin the paet year ❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22a. PLACE OF INJURY-At home, tarm, atreet, lectory, ofHce hui�ding, conatructlon elte, etc. (Specliy)
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<br />22d.INJURYATWORK? 22e.DESCRIBEHOWINJURYOCCURIiED
<br />❑ YES ❑ NO
<br />22t. LOCATION OF INJURY • 3TREET & NUMBER, APT. N0. CITY/fOWN SDQE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Dey,Yr.) 24a. DATE SIaNED (Mo., Day,Yr.J 24b.TIME OP DEATH
<br />,�� July a 2006 .��? . . m
<br />�� '23b.DATESIGNED (Mo.,Day,Yr.) 23c.TiMEOFDEATH � � 24c.PRONOUNCEDDEAD (Mo.,Dey.Yr.) 24d.17MEPRONOUNCEDDEAD
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<br />$mo ul 5 2006 4:50 m $��o
<br />5 23d. To the best of my knowledge, tle�th occurted at the time, dete end plaoe �i 24e. On ihe baels of enamineUon endlor investlgetlon, in my opinlon death occurted et
<br />�� and due to th cau s ted : (Signatura end Title J•� .� ¢� the time, dale and ptace and due to the ceuae(s) atated. (Blgnaiure end 17t1e )♦
<br />~ (.,,� N►- � ~ 8 s
<br />25.DIDTOBACCOUSECONTRIBUTETOTHEDEATH7 28a.HASOR�ANORTISSUEDONATIONBEENCONSIDERED7 28b.WA3CONSENT�RANTED7
<br />❑ YES NO ❑ PROBABLY ❑ UNKNOWN ❑ YES NO Not Appllcable It 28e la NO ❑ YES ❑ NO
<br />27.NAME,TITLEANDADORESSOFCER7IFlER (PHYSICL4N,CORONER'6PFIY81CU1NORCOU ATTORNE'Q (lypeorPdM)
<br />'�ebeaca_�J:� K,. 3�te�:nke, M��D.,� 2116 6d F d1�y Ave..,STE 900, Granrl.Ieland NE 68803
<br />28aRE018TRAR'S SI�NATURE 28b. DATE FILED BY REa1STRAR (Mo., Day, YrJ
<br />: JUL 7 2006
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