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To Be CompletedNerified by: FUN RAL- D1REOTOR _ 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Carol Ann Petersen 2. SEX Female • 3. DATE OF DEATH (Mo.,Day,Yr.) December 27, 2010 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH St. Louis, Missouri 5a. AGE -Last Birthday (Yrs.) 68 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.) April 22, 1942 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 478 -52 -3819 8a. PLACE OF DEATH HOSPITAL; ❑ Inpatient OTHER: ® Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home 0 DOA ❑oc: r;bpeeffy 8b. FACILITY -NAME (If not Institution, give street and number) Madonna Rehabilitation Hospital LTC 8c. CITY OR TOWN OF DEATH (Include Zip Code) Lincoln 68506 8d. COUNTY OF DEATH Lancaster 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 4611 Lakeside Dr. 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® Yes 0 No 10a. MARITAL STATUS AT TIME OF DEATH El Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 19b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Lee Petersen 11. FATHER'S -NAME (First, Middle, Last, Suffix) Raymond Joseph Rupp 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mary Leonie Michelis 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) NO 14a. INFORMANT -NAME Lee Petersen 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION ❑Bonet ❑ ° ° " "' °" ®Cremation ❑Entombment ❑Removal ❑ Othar(spacNy) 16a. EMBALMER-SIGNATURE Not Embalmed lob. LICENSE NO. 16c. DATE (Mo., Day, Yr.) December 30, 2010 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE Aspen Cremation Service Lincoln Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 To Be Completed by: CERTIFIER CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain or events • diseases. Injures, or complications. that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death '/ a .t ( S respiratory arrest, or ventricular fibrhlation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines If necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final 1-----c-, • disease or condition resulting a) PSI I t'G t l I V i e in death) �iJ' DUE TO, OR AS A CONSEQUENCE OF: onset to death • Sequentially Ilat conditions, If b) / � .. 0 Cu 1 h any, leading to the cause listed / (Pon G (9 T .. 1 - 4.-14 ) L V ✓1 s 0 "`S on line 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 IL OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I. 19.yWAS MEDICAL EXAMINER R CORONER CONTACTED? ❑ YES E NO /. IF FEMALE: IS 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 ..„24a. MANNER OF DEATH a Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 22. WAS AN AUTOPSY PERFORMED? ❑ YES KI NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22e. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE CL 12 LL :: ~ 2 16 u Z g 23a OF DEATH (Mo., Day, Yr.) December 27 , 2010 Z } 9 0 ill m S 0 E en a Z 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH m 23b. DATE SIGNED (Mo., Day, Yr.) 'December 28, 2010 23c. TIME OF DEATH 7:1 a m 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD m u . 0 0 1x1 =O o U 23d To the best of my knowledge, death occurred at the time, date and place O W z a 6 t, and due to the c (s) stated. (Signature and Title) , Z G o W „ X1,1 O g‘,0 t rim r -t ~ o `O 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) 3 DID TOBACCO USE CONTRIBUTE TO THE DEATH? E YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ✓ ❑ YES ® NO 2AS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ NO 27j NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) ✓ Daniel B. Einspahr, MD 3901 Pine Lake Rd, Suite 220 Lincoln, NE 68516 P \i0 28a. REGISTRAR'S SIGNATURE oxCr 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) DFC 8 20111 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF H a "H AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARYMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORS 'pbR VITAL"RECORDS. • DATE OF ISSUANCE JAN 0 42011 201304016 % STANLEY S. COOPER ' ASSISTANT. STATE REGISTRAR DEPARTMENT OF HEALTH AND ;. HUMAN SERVICE` STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES • C ERTIFICATE OF DEATH 1 30865 LINCOLN, NEBRASKA