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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 DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR. VITAL RECORDS. f . a 0 1, DECEDENT'S - NAME (Fifa', Frances - Middle, Louise Last. Tjaden Su III I) 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Keystone, Nebraska 7. SOCIAL SECURITY NUMBER 506 - 28 - 305 4 Bb. FAG 'Li TY•NAME (It not Institution. give street and numberl St. Francis Medical Center 2620 West W. Faidley Avenue BC. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 Pa. RESIDENCE -STATE Nebraska 90 STREET AND NUMBER 1401 East Street 9b.000NTY Hall hi k. AiA Hi tAL 5 TA'U:i AT TIME Or. DEA fel xl Named J Never Names :..1 Mauled. but separated ❑ Widowed O Divorced ❑ Unknown 5a. AGE -Last Birthday (Yrs.) 74 11. FATHER'S NAME (First, Clyde Ogg Middle, Last, Sut(lx) 13. EVER IN U.S. ARMED FORCES? Give dales or service II yes. (Yes. no, or unk.) NO 15. METHOD OF DISPOSITION Burial 1 Donation U Cremation U Entombment U Remova! Other (Specify) Sb. UNDER I YEAR MOS. 8a. PLACE OF DEATH H-OSPITA(,: )11) Inpatient OINEFt U Nursing HOmeA.TC CI HospiceFaciIily ❑ ER /Oul !alien t.0 Decedent's Home ❑ DDA ❑ ofrier(spedN) 9c. CITY ORTOWN Wood River Wesley Tjaden, Senior 14a. INFORMANTNAME Wesley Tjaden Sr 16a. EktBy il- SIONATTUF DAYS be. APT. NO 2. SEX Female Sc. UNDER I DAY HOURS MINS. 91. ZIP CODE 68883 !9b. NAME OF SI�OUSI• (First, Middle, Last. Junk) a vale. give maiden name.. 8d. COUNTY OF DEATH Hall 12. MOTHER'S•MAME (Firs Bertha Marshall Middle. Maiden Surname) 16b. LICENSE NO. 1191 17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street. City or Town. Stale) Livingston- SondermannFuneral Home... 601 North Webb Road, Grand Island,Nebraska 3. DATE OF DEATH IMo.. Day. Yr.) November 9, 2006 6. DATE OF BIRTH (Mo.. Day, Yr.) May 31, 1932 93. INSIDE CITY LIMITS 4 YES U NO 14b. RELATIONSHIP TO DECEDENT Husband 16c. DATE (MO.. Day, Yr. I November 13, 2006 16d. CEMETERY. CRE ORY OR OTHER L CITY! TOWN Westlawn Memorial Park Cemetery Grand Island STATE Nebraska I 7b. ZIP Code 68803 CAUSE OF DEATH (See instructions and examples) is PART I. Enter the pain or evenis•- diseases. 'Nunes. or complications-Star direc'ly caused IRe death. DO NOT enter terminal events Michas cardiac arrest, respiialory a!rest, or ventricular liblrRalion without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a tine. Add additional lines it necessary. IMMEDIATE CAUSE: `V11 tk&Yy\ Sct 1 \ IMMEDIATE CAUSE (Final disease or condition resufklg it dealt) Sequentially IlstConditions, D any, leading to the causeHled on fines. Enter fie UNDERLYNGCAUSE [disease or Injury that initiated the events resulting In dean) LAST t8. PART II. OTHER SIGNIFICANT CO contnbulin to Ong death but not resulunge) the underlying cause given in PART I `] ZN L`j 1(Li1� C � .�hJ o"r O� \ � L /NA I LK1Z 4 FEMALE: of pregnant within past year ❑ Pregnant al lime of death U Not pregnant, but pregnant within 42 days of death L I Nol pmegnanl.Out 43 days 10 I yearbetore 0 unknown it pregnant within the pas' yeat 22e. DATE OF INJURY (No. Day, Yr .I V) Pt 22d. INJURY AT WORK'! 221. LOCATION OF INJURY • STREET & NUMBER, APT NO. g z aO a $ o : DATE OF ISSUANCE NOV18 011 LINCOLN, NEBRASKA ❑ YES LINO 28e. REGISTRARS SIGNATURE STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUP P �} � 1 7 [ CERTIFICATE OF DEATH u [ �J (a) DUE TO:OR AS A CCNSEQUENCE OF: Ili) DUE TO.OR AS A CONSEQUENCE OF: ` U* 1-rQC cis- \! VO lc) Id) 2'X. DATE SIGNED GNED (Mn.. Day, Yr.) 1 - b(a DUE TO. OR AS A CONSEQUENCE OF: 220 TIME OF INJURY m 22e. DESCRIBE HOW INJURY OCCURRED DATE OE DEATH (Mo.. Day. Yl ke DID TOBACCO USE CONTRIBUTE TO THE DEATH? 201303479 21 ..MANNER OF DEATH / Natufal ❑ Homicide ❑ ACcidenl0 Pending investigation ❑ SWdde 0 Could not be determined TIME OF DEATH ("Lan p.m �(d To the beat 01 my knowledge, acorn daunt al me lime. dale and place and due to Ih1ya.eere) sienA Slg1 a ryt and Tihee 1 V STATE OF NEBRASKA CITY/TOWN IF TRANSPORTATION INJURY U Driver/Operalor ❑ Passenger ❑ Pedestrian ❑ Other (Speoly) 24a. DATE SIGNED (MO„ Day,Yt.) . HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES XNO U PROBABLY 0 UNKNOWN 0 YES FJYNO NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OA COUNTY ATTORNEY) (Type or Print) L. _ �. 1t - T O O. LS STANLEY S COOPER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE 24c. PRONOUNCED DEAD (Mo.. Day. YO APPROXIMATE INTERVAL I gdsellddeath 3d rvAt onset to death I onset to death onset to death i WAS MEDICAL EXAMINER OR CORONER CONTACTED' 0 YES XNO ' CC. WAS AN AUTOPSY PERFORMEO7 0 YES NO Q WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ONO 22C. PLACE OF INJURY -AI home. (arm. sheer, factory. oliCe building. construction sill. etc. (Specoly) 24o. TIME OF DEATH WOV 1 3 2006 ZIP CODE m 24d. TIME PRONOUNCED DEAD Tn 24e. On the oasis of examination and/or uweskgahon, m my opinion death occwred at Ina lime, dale and plate and due to the cautelsl stated. (Striatum and Till.) • 211. WAS CONSENT GRAN Y / / Not Applicable II26a is NO CI YES /3 NO 26b. DATE FILED BY REGISTRAR Is1o.. Day. Yr.)