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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. , DATE OF ISSUANCE MAY 2 6 2009 LINCOLN, NEBRASKA 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 West Second, Grand Island, NE. 17b. Zip Code 68801 1. DECEDENT'S -NAME (First, Petrina 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Junction, Colorado 7. SOCIAL SECURITY NUMBER 522 -11 -0056 8b. FACILITY -NAME (If not institution, give street and number) Home: 4336 Sherwood Road 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 9a .RESIDENCE-STATE Nebraska 9d. STREET AND NUMBER 4336 Sherwood Road 10a. MARITAL STATUS AT TIME OF DEATH a Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, 13. EVER IN U.S. R ARMED FORCES? Give dates of service if yes. (v - 2001 2-11-2002 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation Q[Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) e......._ 8. PART 1 Enter the chain of events--diseases, Injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, 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 disease or condition resulting In death) Sequentially list conditions, If any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or Injury that initiated theevents resulting in death) LAST STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND 9UPPORFl 9 CERTIFICATE OF DEATH f T Henry ( Terminal Angiosarcoma Cancer DUE TO, OR AS A CONSEQUENCE OF: (b) DUE TO, OR AS A CONSEQUENCE OF: (c 22a. DATE OF INJURY (Mo., Day, Yr.) Middle, Middle, Mae 68803 9b. COUNTY Hall DUE TO, OR AS A CONSEQUENCE OF: 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 YY Unknown if pregnant within the past year 22b. TIME OF INJURY 01 201305385 Last, Gruhn 5a. AGE -Last Birthday (Yrs.) 37 Last, Suffix) Rider 14a. INFORMANT -NAME Dana Gruhn 68. EMB MER- SIGNATU 1 64. CEMETERY, EMATORY OR 0TH LOCATION Westlawn Memorial Park Crematory, Grand Island, Nebraska (d) 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the unieriyiny cause given in PART 1. 21 a. MANNER OF DEATH Xl Natural 0 Homicide ❑ Accident❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED CI YES ❑ NO 221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (MO., Day, Yr.) z 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIME OF DEATH r m ara 235. DATE SIGNED (Mo., a v ¢ 5 -15 -09 2: a to NED (M Day, Yr.) 23c.TIME OF DEATH �' 24c. PRONOUNCED DEAD (Mo., Day,Yr.) 244. TIME PRONOUNCED DEAD � m m as J E- � � - E m O 23d. TO the best m the cause(s) stated. (Signature and Title ♦ the time, date and place w 8 O 24e. On the basis of examination and /or Investigation, in my opinion death occurred at and due to th Y knowledge, g death occurred $ z p the time, date a. •place and due to the cause(s) stated. (Signature and Title ) • g e O d � o � �^ Deputy Hall Atto nay Q 25. DID TOBACCO USE CONTRIBUTE TOTHE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ❑ YES ❑ NO 0 PROBABLY X�C UNKNOWN 0 YES $1 NO Not Applicable if 26a is NO ❑ YES Xi NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Sarah Carstensen, Deputy Hall County Attorney 231 Smith �] (Mo., ) RAM 28b. DATE FILED BY REGISTR M 28e REGISTRAR'S SIGNATURE MAY 2 I ZOOJ STATE OF NEBRASKA Suffix) 8a. PLACE OF DEATH HOSPITAL: 5b. UNDER 1 YEAR MOS. DAYS ❑ Inpatient ❑ ER /Outpatient 0 M HOURS 9c. CITY OR TOWN Grand Island S7`AN4) 45.SISTAitg7 $ ATE zriolr< 6E rip4 Ni,,of- kiEALTH•AN9f, HUMAN $2„g ,V.CE ' 71` -4 2. SEX Female 5c. UNDER 1 DAY MINS. OIdED ❑ Nursing Home/LTC ❑ Hospice Facility II Decedent's Home ❑ Other(Specify) 8d. COUNTY OF DEATH Hall 9e. APT. NO 12. MOTHER'S -NAME (First, Karleen 16b. LICENSE N0. / 328 CITY / TOWN 1 91. ZIP CODE 68803 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Dana Gruhn 210. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 3. DATE OF DEATH (McoDay,Yt) May 13, 2009 6. DATE OF BIRTH (Mo„ Day, Yr.) August 28, 1971 Middle, Maiden Surname) K. Gilbert 14b. RELATIONSHIP TO DECEDENT Husband 16c. DATE (Mo., Day, Yr. ) May 18, 2009 STATE onset to death onset to death onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? XKYES ❑ NO 21c. WAS AN AUTOPSY PERFORMED/ ❑ YES XIN0 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETECAUSE OF DEATH? ❑ YES gp NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 9g. INSIDE CITY LIMITS XI YES ❑ NO APPROXIMATE INTERVAL 2 1/2 years onset to death HHS -61 11/03(55061)