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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 OE HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITALL,fi'ECORp.S? ,{ • �I�� • u i , ` el STANL,EKY.S.- COOPER " ASSISTANT STATE - REGISTRAR DEPARTMNT OF HEALTH AND HUMAW FRVkES DATE OF ISSUANCE JAN 21 2009 LINCOLN, NEBRASKA STATE OF NEBRASKA 201306718 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 1 p A 0 0 RCRTICIRATF AF r1FATH 5�7 4� f► 1l v Am11:4? tt 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Kenneth Alan Olesen 2. SEX Male 3.,DATE bUATH IMo.,D1iy,Yr4 , January'3, 2009 ■ 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Pierre, South Dakota 5a. AGE -Last Birthday (Yrs.) 72 fib. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.) September 29, 1936 MOS. DAYS HOURS MINS. (17) To Be Completed by: CERTIFIER _ 1 To Be Completed/Verified by: FUNERA TOR 7. SOCIAL SECURITY NUMBER 50444 -3551 8th PLACE OF DEATH HOSPITAL: © Inpatient OTHER; ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home 0 DOA ®.1sfeDify) 8b. FACILITY -NAME (ti not Institution, give street and number) Saint Francis Medical Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) 1 8d. COUNTY OF DEATH Grand Island 68803 1 Hall 9th RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER - 3207 Knights Rd 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® Yea ❑ No 10a. MARITAL STATUS AT TIME OF DEATH RI Married ❑ Never Married ❑ Married, but separated ❑ endowed ❑ Divorced ❑ Unknown *lb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Alvin, Mae Dreier 11. FATHER'S -NAME (First, Middle, Last, Suffix) Oge Olesen 12. MOTHER'S -NAME (First, Middle. Maiden Surname) Eleanor Ramser 13. EVER IN U.S. ARMED FORCES? Give dates of service N Yes. (Yes, No, orunk.) 11/6/56- 11/10/58 14a. INFORMANT-NAME Alvina M Olesen 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Bawl ❑Don tlen - Cremation Entombment ❑Removal ❑Otler(apecity) 18LE LINER- SIGNATURE, . - "'j ,, / a z ( 18b. LICENSE NO. 1092 18c. DATE (Mo., Day, Yr.) January 9, 2009 18d CEMETERY, CREMATORY OR OTHER LOCATION CITYITOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 17b. Zip Cods 6 f 5 E13 12 CAUSE OF DEATH (See instructions and examples) ' 11. PART I. Enter the RBR or w+nes -disease, attunes, or complications. that directly c+weat ths dean, DO NOT safer ve nxl create such as candles ante, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE Enter only one cause on a this. Add additions! lines it necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final disease or condition resulting a) Q, IS In death) a a /J►t� - El 1 . _ DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, H b) any. leading to the cause listed on line a DUE TO, OR AS A CONSEQUENCE OF: OFZIG1NAL onset to death Enter the UNDERLYING CAUSE c) (disease or injury that initiated onset to death the events recanting in death) DUE TO. OR AS A CONSEQUENCE OF: LAST d) 18. PART U. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the G 1 �y® i {�p - ,/�,,� ,, • - ,. i�Cb O ^" �� \L underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ICI No 20. IF MALE: ❑ 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. NER OF DEATH 131.Mrural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be dstemlined b. IF TRANSPORTATION INJURY ❑ DrivedOperator ❑ Passenger ❑ Pedestrian ❑ Otl10f (SPAY) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES 'a.tttt 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At horns, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES IR< 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) 1.5 Januar 3, g t E m 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH m .00 23b. DATE SIGNED Mo., D YrJ a January 2 23e. TIME OF DEATH 10:20 a m 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCFA DEAD m • ,. e, death occurred at e et . 23d. To the . my th a e d due to the -. ,.: a) eta ,: • (S re and Title) o �y fa '_ fS/ , 25. DID TOBA US _ CONTRIBUTE TO THE DEATH? ❑YES !a Y 0 0 PROBABLY 0 UNKNOWN time, date and place 8 W 2 C 2 C, K ~ U O 28a. HAS ORGAN OR TISSUE DONATION ❑ YES M NO 24e. On the basis of examination at the time, dab and place BEEN CONSIDERED? and/or investigation, In my opinion death occurred and due to the cause(s) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable K 26a is NO ❑ YES gi NO 27. NAME, TITLE A • ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Ryan D. Crouch D.O. 800 N. Alpha St Grand Is and, NE 68803 P 28a. REGISTRAR'S SIGNATURE ,d� ll A '' '" 28b DATE FILED BY REGISTRAR (Mo., Day, Yr.) JAN 7 2009 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 OE HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITALL,fi'ECORp.S? ,{ • �I�� • u i , ` el STANL,EKY.S.- COOPER " ASSISTANT STATE - REGISTRAR DEPARTMNT OF HEALTH AND HUMAW FRVkES DATE OF ISSUANCE JAN 21 2009 LINCOLN, NEBRASKA STATE OF NEBRASKA 201306718 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 1 p A 0 0 RCRTICIRATF AF r1FATH 5�7 4� f► 1l v Am11:4? tt