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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />FEB 0 5 2009
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORb 2 w
<br />CERTIFICATE OF DEATH C9. 082'
<br />8 �}
<br />15. METHOD OF DISPOSITION
<br />(Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16d. CEMETE % CREMATORY OR 0 ER LOCATION
<br />Cameron Cemetery
<br />CITY / TOWN
<br />178. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 West Second, Grand Island, NE
<br />Wood River,
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />16b. LICENSE NO.
<br />1.329
<br />18c. DATE (Mo., Day, Yr. )
<br />January 31, 2009
<br />STATE
<br />7. SOCIAL SECURITY NUMBER
<br />523 -19 -9867
<br />8b. FACILITY -NAME Of not institution, give street and number)
<br />8020 N. Equus Lane
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Cairo 68824
<br />9a. RESIDENCE -STATE 9b. COUNTY
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />8020 N. Equus Lane
<br />108. MARITAL STATUS AT TIME OF DEATH gl Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle,
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If yes. 14a. INFORMANT -NAME
<br />(Yes, no, or unk.) No
<br />Last, Suffix)
<br />Harlan E. Surprenant
<br />8a. PLACE OF DEATH
<br />HOSPITAL:
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Don Wetterer
<br />Don Wetterer
<br />❑ Inpatient
<br />❑ ER /Outpatient
<br />❑ Da4
<br />9c. CITY OR TOWN
<br />Cairo
<br />9e. APT. NO
<br />HOURS
<br />MINS.
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9f. ZIP CODE
<br />68824
<br />12. MOTHER'S -NAME (First, Middle,
<br />Friedel
<br />QM: ❑ Nursing Home /LTC ❑ Hospice Faculty
<br />51 Decedent's Home
<br />❑ Other (Specify)
<br />9g. INSIDE CITY LIMITS
<br />❑ YES k6 NO
<br />Maiden Surname):
<br />Stadler
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />1. DECEDENT'S -NAME (First, Middle, Last,
<br />Christianna Marie Surprenant
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Bitburg, Germany
<br />18. PART I. Enter the chain of events -- diseases, injuries, or complications - -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. D0 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE: nn l
<br />(a) M1�klgIJ `}-k •� `� RS1� 1' \�ll� 4 1
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In death)
<br />Sequentially Ilstconditions, If
<br />any, leading to the cause listed
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that Initiated
<br />the events resulting In death)
<br />LAST
<br />22a. DATE OF INJURY (Mo.
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />28a. REGISTRAR'S SIGNATURE
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(b)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(d)
<br />18. PART U. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />ear
<br />Day, Yr.)
<br />N �� .
<br />22b. TIME OF INJURY
<br />m
<br />21a. MANNER OF DEATH
<br />latural ❑ Homicide
<br />❑ Accident CI Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES s lid NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />❑ YES NI[NO
<br />22c. PLACE OF INJURY -At home, fa m, street, factory, office building, construction site, etc. (Specify)
<br />20. IF FEMALE:
<br />g Not pregnant within past
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c.TIM
<br />23d.To the best of my knowledge, death occur ed at
<br />and due to tl�Bae�e(s) state . S' rE a
<br />e time, date and place
<br />itle ) •
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />m
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY- STREET & NUMBER, APT. NO.
<br />23a. DATE OF DEATH (Mo., Day,Yr.)
<br />❑ YES 'NO ❑ PROBABLY ❑ UNKNOWN
<br />STATE OE NEBRASKA
<br />2 01307515
<br />❑ YES
<br />CITY/TOWN
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />47
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER ( PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Steven Husen M.D. 2116 W. Faidley Ave., rand Island, NE
<br />CfNO
<br />5b. UNDER 1 YEAR
<br />Suffix)
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />STATE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />STANLY S: COOPER
<br />.ASSISTANT STATE R
<br />DEPARTMENT OF HEALTH AND
<br />'HUMAN SERVICES
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 26, 2009
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />August 1, 1961
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />onset to death
<br />onset to death
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ' NO
<br />ZIP CODE
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title) •
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES
<br />68803
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />N
<br />FEB 3 2009
<br />
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