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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Linda Darlene Lorenzen 2. SEX " . Female 3. DATE OF DEATH (Mo., Day, Yr.) January 17, 2013, 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE • Last Birthday (Yrs.) 64 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) February 18, 1948 MOS. I DAYS HOURS MINE. 7. SOCIAL SECURITY NUMBER 508-68 -1659 813. FACILITY -NAME (If not Institution, give street and number) 7501 S. Monitor Road 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 913. COUNTY Hall 9c. CITY OR TOWN Grand Island 7501 S. Monitor Road re. APT. NO. 9f. ZIP CODE I 68803 9g. INSIDE CITY LIMITS I ❑ YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Larry Lorenzen 11. FATHER'S -NAME (First, Middle, Last, Suffix) Vernon Wetzel 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Evelyn Fleshman 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Larry Lorenzen 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a, EMBALMER-SIGNATURE Not Embalmed 16b. LICENSE NO, 16c. DATE (Mo., Day, Yr.) January 18, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Crematory Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston - Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 17b. Zip Code 68803 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 18. PART I. Enter the chain of events -- diseases, injuries, or complications•that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death 5 Years respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Chronic Obstructive Pulmonary Disease disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) any, leading to the cause listed line on a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or injury that Initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ® Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could determined 2113. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE Or INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE .8' W 9 IL E ,.. g Y E U i 23a. DATE OF DEATH (Mo., Day, Yr.) To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) January 18, 2013 24b. TIME OF DEATH 06:57 AM 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH I 24c. PRONOUNCED DEAD (Mo., Day, Yr.) January 17, 2013 24d. TIME PRONOUNCED DEAD 08:42 AM 8 g 0 9d. To the best of my knowledge, death occurred at the time, data and place .8 8 and due to the cause(s) stated. (Signature nd Title) z 24e. On the basis of examination and/or Investigation, In my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Barbara Dunn, Hall Deputy County Attomey 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable H 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Barbara Dunn, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 1285. REGISTRAR'S SIGNATURE f� r � h _� _ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 22, 2013 DATE OF ISSUANCE STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPART ,7ENTpF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. 201301083 STANLEY S. COOPER .. DEPARTM - OE N TH AND ' • LINCOLN, NEBRASKA HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES '� i �{ A e' ' - t'. CERTIFICATE OF DEATH 01/29/2013 13 00258