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STATE OF NEBRASKA 201306617
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTHNI HUMAN SERVICES,IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAS A. a?IRTMENT OF HEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FO1 ITA1 RECORDS . _
<br /> `•
<br /> DATE OF ISSUANCE `'
<br /> t gTAN4Et S COOPER
<br /> FEB 0 ,ASSI$JANTSTATEREGISTR4R'
<br /> 'DE?AP #ENTOFHEALTH.A lD
<br /> LINCOLN, NEBRASKA . . . (.=ILAWN SERVICES • 0--
<br /> F STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE ANE)SUP r"..,
<br /> CERTIFICATE OF DEATH
<br /> • c-E? 1.DECEDENT'S-NAME (First, Middle, Last, Suffix) 2.SEX 3,BATE OF DEATH'{Mo.,Day,Yr.)
<br /> � Harry • Thor Bulow Male February 8, 2009
<br /> °v'. ?t 4.CITY AND STATE OR TEAR€TORY,OR FOREIGN COUNTRY OF BIRTH 5a.AGE-Last Birthday L 56.UNDER 1 YEAR Sc.UNDER 1 DAY 6.DATE OF BIRTH(Mc.,Day,Yr.)
<br /> 1 MOS. DAYS HOURS INNS.
<br /> (Yrs.) 8fl
<br /> Copenhagen, Denmark March 17, 1928
<br /> ' fj 7.SOCIAL SE NUMBER 8a.PLACE OF DEATH
<br /> 508-34-1961 HOSPITAL: C]Inpatient MED ❑Nursing Home/LTC ❑Hospice Facility
<br /> f -; Bb.FACILITY-NAME (If not institution, give street and number')
<br /> ER/Outpatient Decedent's Home
<br /> °' Home: 124 Ponderosa Drive 3 ❑ C, ❑Other(Specify)
<br /> .-\\\\\\ -..0Z
<br /> 8c.CITY OR TOWN OF DEATH (Include Zip Code) 8d.COUNTY 0FDEATH
<br /> Grand Island 68803 Hall
<br /> 9a.RESIDENCESTATE GS/COUNTY 9c,CITY ORTOWN
<br /> Nebraska Hall Grand Island
<br /> - 9d,STREET AND NUMBER 9e.APT.NO 9f.ZIP CODE 9g.INSIDE CITY LIMITS
<br /> -1,; 124 Ponderosa Drive 68803 X3 YES ❑ NC
<br /> 10a.MARITAL STATUS AT TIME OF DEATH amarried 0 Never Married lob.NAME OP SPOUSE(First,Middle,Last,Suffix)If wile,give maiden llama,
<br /> ❑Married,but separated ❑Widowed ❑Divorced ❑Unknown Ila Tschudin
<br /> a1 11.FATHER'S-NAME (First, Middle, Last, Suffix) 12.MOTHER'S-NAME (First, Middle, Maiden Surname)
<br /> Holger Bulow j Carla Mikkelsen
<br /> I 13.EVER IN U.S.ARMED FORCES?Give dates of service if yes. 14a.INFORMANT-NAME 14b.RELATIONSHIP TO DECEDENT
<br /> =_, (Yet,itdso?unR1]-2-1951 12-3-1952 Ila Bulow Wife
<br /> v• 15.METHOD OF DISPOSITION 16a.EM SIGNATURE 1 155.LICENSE NO. 15c.DATE (Mc.,Day,Yr.)
<br /> T g4Burial ❑Donation � (J��y� I /2 r' t February 14, 2009
<br /> i ❑Cremation ❑Entombment 16d.CEMETERY,CREMATOR`I OR OTHER LOCATION C[TY I7OWN STATE
<br /> ❑Removal ❑Other(Specify)
<br /> Grand Island Cemetery, Grand Island, NE
<br /> ',I:
<br /> = i 175.FUNERAL HOME NAME AND MAILING ADDRESS (Street,City orTown,State) 17b.Zip Code
<br /> i Apfel Funeral Home, 1123 West Second, Grand Island, NE 68801
<br /> 4,: .f-`+.`s'' n':.RiV7` r� 'a' -i e >irs F'1�-:a,-'w=.',. --ti4 g ' C> i i k�'r'=b r. n- r"-_ i '' �'
<br /> ., .�-._._ ,sr-, s.Y: .� s�* .-. _u-� a'r. - �� r, -f�: . .� �„'-.v`.��c'=y--fir-:.�-',. .. ,s��ren;'� y, ,�,z.r' X,�"Y;,,r �' n-::.-+�
<br /> 18.FART I.Enter the chain El events-diseases,injuries,orcomplications--thatdirect[y caused the death.DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br /> ,e respiratory arrest,or ventricular fibrillation without showing the etiology.DO NOT ABBREVI ATE.Enter only one cause on a line.Add additional lines if necessary. I
<br /> IMMEDIATE CAUSE: onset to death
<br /> . go ]MMEDtaTE CAUSE(Final
<br /> (a) /Yl C7 1-,7 � � -"7 s��y' �f!/�'7L � /(2_ e*`3-
<br /> t cGw oeorcondition resulting DUETO,OR AS ACONSEQUENCE CF: / l ansetto death
<br /> in deetfi)
<br /> 4 Sequentially listcond'itions,iT @) /G �<Y L I
<br /> � any,leadingtethe cause listed DUE TO,OR AS A CONSEQUENCE OF: ] onset to death
<br /> ifb
<br /> on lines. '
<br /> EntertheUNDERLYING CAUSE
<br /> (disease orinJurythatinitiated (c) ---
<br /> ri t6eeventsresulting IR death) DUE TO,OR AS A CONSEQUENCE CF:
<br /> !AST [ onset iodeath
<br /> I
<br /> . ` 18.PART II.OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in PART I. 119.WAS MEDICAL EXAMINER .
<br /> ; '. OR CORONER CONTACTED?
<br /> ',;.C, ❑ YES a -FFO
<br /> y '' 28-IF FEMALE. 21a.MANNER OF DEATH 215-IFTRANSPORTATIOTJ INJURY 21c.WAS AN AUTOPSY PERFORMED?
<br /> ❑Not pregnant within pastyear L"7 Natural ❑Homicide ❑Edver/Operator
<br /> F1 ❑Pregnant at time of death ❑Accident❑Pending Investigation
<br /> ❑Passenger ❑ YES FLi10
<br /> '"err ❑Not pregnant,but pregnant within 42 days of death ❑FetBSinan 21d.WERE AUTOPSY FINDINGS AVAILABLE TO
<br /> ' .. ❑Suicide ❑Could not be determined
<br /> OA ❑Not pregnant,but pregnant 43 days to t year before death ❑Other(SpecHy) COMPLETE CAUSE OF DEATH?
<br /> :74.-e. ❑Unknown it pregnant within the past year LI YES LI NO
<br /> k,+e„:, 22a.CATE OF INJURY(Mu.,Day,Yr.) 226.TIME OF INJURY 22e.PLACE OF INJURY-At home,farm.street,factory,office building,construction site,etc.(Specify)
<br /> is
<br /> "; 22d.INJURY AT WORK?
<br /> 22e.DESCRIBE INJURY OCCllRREO
<br /> r,241P
<br /> : _ LJ YES [I NO
<br /> ii,-iLt4J 22f.LOCATION OF INJURY-STREET&NUMBER,APT.NO. CfTY/TOWN STATE ZIP CODE
<br /> Ake
<br /> Aft 23a.DATE OF DEATH(M0.,Day,Yr.) 24a.DATE SIGNED(M0.,Day,Yr.) 246.T1ME OF DEATH
<br /> • -"5 / /Z�`(?9 tea, m
<br /> W
<br /> a U
<br /> A Q,J 235.DAT SIGNED(Mo.,Day,Yr.) � 23cTIME OF DEATH /� 7,_r 24c.PRONOUNCED DEAD(Mn,Day,Yr.) 24d.TIME PRONOUNCED DEAD
<br /> 'I=,�-��-`. s E z Z//7! G cOP e9 I �'�5 ! m ....y m
<br /> '* i'.5- 23d.To the bestoi my knowledge,death occu -,,at the time,date and place al? 24e.On the basis of examination and/or investigation,in my opinion death occurred at
<br /> ii1:1,c m and duet he cause(s)Ss)si ed.{Signs i -and Title)• s O o the time,date and place and due to the cause(s)stated.(Signature and Title)t/
<br /> .,'}y 12 S. f O 2 U
<br /> • 25.0IDTOBA000 USE OO RIBUTETOTHE DEATH? 26a.HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b.WAS CONSENT GRANTED?
<br /> Sa: ❑YES re"{-10 ❑PROBABLY ❑ UNKNOWN L❑YES CPIS- Not Applicable it 26a is NO ❑YES 0 NO
<br /> k_S 27.NAME,TITLE AND ADDRESS OF CERTIFIER(PHYSICIAN CORONER'S PHYSICIAN OR COUNTY ATTORNEY)(Type or Print)
<br /> i Gary Settje N.D. 2116 W. Faidley Ave. #400, Grand Island, NE. 68803
<br /> 28a.REGISTRAH'SSIGNATURE 26B.DATE FILED BY REGISTRAR(Mc.,Day,Yr.)
<br /> FEB 13 2009
<br /> 1
<br /> HHS-S1 11703(550611
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