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STATE OF NEBRASKA <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND..ij U <br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA,DePAI4 fNT, <br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR 'VI k ,,y <br />DATE OF ISSUANCE <br />02/02/2012 <br />LINCOLN, NEBRASKA <br />201309740 <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN <br />CERTIFICATE OF DEATH <br />AE ME 1� <br />DEF�irl � AFIID <br />HU!fA 3 SERVICES? <br />UJ. „-g/' ; .r, r,, ,. <br />:2�� 2x566 <br />1 <br />0 <br />1. DECEDENTS- IAME.'.I(FIRIR Mlkdl%. <br />John Charles Houselog <br />4.. CITY ANOMIE OR TERRITORY, OR FOREIGN COUNTRY OFEIRT11 <br />Lake Benton, Minnesota <br />Sties) <br />a ray.Madntm"n.6.u.e ‘Nkt a ..S <br />dn"M D11E A $A OF: <br />Onor thUNDEg1.YNOCAUSE C) 1 ' tom O <br />(cheese or injury tlltbktrad DUE TO,.OIl AS ACO►NE <br />to suede nwteu in tine) <br />LAST <br />Male <br />Ss. :AOE4ae 9kggg <br />(Mrs.) <br />81 <br />Vb. UNDER 1 YEAR <br />MOS. <br />SC. UNDER 1 DAY <br />DAYS : HOURS <br />20. F MAWS: <br />❑Not Pregntld within in p..tywr <br />21e. MANFER OF DEATH <br />Newt ❑ Homicide <br />i]►nWtlk at &lo ol d..Ih ❑ dent 0 Patens investigation <br />0/1e pregnant, but pregnNKwN 42 days at death ❑ Sulfide ❑ Could not be determined <br />ONO. Pr•Prw*. it Pregnant 43 days toyer before den <br />QUtkmoen if pompon within we Pee year <br />21b. IF TRANSPORTATION NJURY1 <br />❑ D lvedOpN.tor <br />❑ Pedestrian <br />©ott.rspawn <br />s. DATE OF DEATH (Mo Dq.W-) <br />January 24, 2012 <br />0. DATE OfINRTN (MD..O.y, Yr.) <br />April Z 1930 <br />SECURITY NUMBER <br />263-40 -2854 <br />Ob. FACOJTY-NAME(B not ys aon,ywsMlatdn <br />Veterans Affairs Medical Center <br />Se. CRY OR TOWN OF DEATH (Wade cep Coda) <br />Grand Island 68803 `< <br />id. COUNTY OF DEATH <br />Hall <br />0.. RpM>ENCE4TATE <br />Nebraska <br />9d STREET AND NUNd!R :. <br />2018W. St <br />ab. COUNTY C. <br />Hall <br />9c. CITY OR:Weal :. <br />Grand Island <br />0.. APT. NO. :'. <br />68803 <br />49. INSIDE CITY WMS <br />E Y.. 0 110 <br />10.. MARITAL STATUS AT TIME OF DEATH ® MWISd: ❑ Never Maned <br />0 Married. but separated ❑ Mowed. ❑ Divorced: ❑ Unknown <br />11. FATH6PS t OUSE (Hill. Middle, ;.:1..N, '.Sndt=) <br />John B Houselog ;; <br />105. NAME OF EPOusE (FOE, :mad.. Let`.. souls) t off% give Nab)se nn <br />Shirley Roush <br />12. MOTHEN'S•NAME : (Flat. Mudd. <br />Arlie Pease <br />13. EVER N U.S. : ARMED FORCES? Glv.d,t.. of porch N Yes. <br />elm, No, ar unk. Yes 4/14/49-11/1.4/52 <br />Ua:NFORMANT.NAME <br />Shirley Houselog <br />103. RELAI1ONSIIPTODE ECelIT <br />we <br />16. METXODOF:DISPOTIMON 10.. EMBAI.MEMSIONATtRE <br />� °i1tl D ge1MQ0A Not Embalmed <br />105. LICENSE NO. <br />10o. DATE:(Mo.. 0 ay. <br />Jan. 25, 2012 <br />10d CEMETERY, CREMATORY ORO11 LOCATION <br />WestIawn Memorial Park Crematory <br />crremlral <br />Grand Island <br />STATE <br />Nebraska <br />1t+.fUNERAl)OME1tAMEAND MAILING ADDRESS (Wren D1ty et UM, RED <br />Livingston- Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska <br />11b.ap Code <br />68803 <br />CAUSE OF DEATH ( See instructions and examples) <br />w.o.aq.rdr aapNtM do NOr «r+.n.ner...M....w.arr...na6 <br />1..PAaT LOOS/INS aFe619C� - a msaaa.UMMW ,ar ekeogy <br />NWtuttemit. a,uMoI I0.0NIts* uutst tigMta..MD. 00 NOT MNtlIIMTE mew 0.y awa OWMaryw.. Ada aa.tlwW Era W awry. <br />CAUSE <br />WNEDUTE CAUSE (FT.d 6 <br />disease ar saglUon ampullae tullae 944 <br />In death RC dY V �t'tNC,t� ts L <br />. 1_14. PART S. OTHER SIONIF A � <br />Hr CONs contenting to to death but n irvanas In <br />,t10r' i1ukktr <br />A}r 'at <br />21d. WERE AUTOPSY FINCOIOSAVALADLE <br />TO COMPLETE CAUSE OF DEATH? <br />❑ Yes 0 N <br />22s. DATE OF WJURY (Mo. Day, Yr.) <br />22b.11M0OF.INJURY <br />m <br />22c. PLACE OF INJURY III boa.. M EL street, Tacbry, dace buMAlop, CNOIueton dm, stc.: ppm:1W :. <br />22. DATE OF DEATH (Mo., Day, Yt.) :;.. <br />Jan. 24. 2012 <br />DATE OWNED (Mo Day. Yr.) <br />L <br />war a+l, aota <br />0 , <br />ADDRESS OF CERTIFIER (PNYBICYW. PNYSN:IAN ASSISTANT CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type: or Pratt) <br />V s VA N' <br />g <br />DID TOI <br />]�_ ❑ YES <br />�71. NAME. TITLE <br />PROBABLY <br />HAS 0R0AN <br />❑ YES <br />0R <br />24e. DATE SIGNED (Moo. DIY. Tr.) <br />34c. :PRONOUNCED DEAD (Mo., Day. Yr.) <br />TRME: OFDEATH <br />tad 1MRE PRONOUNCED DEAD <br />_ WAS CONSENT GRANTED? <br />Not Apple/Do B MO. M NO ❑ YES :. <br />2W. DATE .FILED EY REGISTRAR (Mo.. Day. Yr.) <br />JAN 302012 <br />m <br />2 0e OnSteMW ofesantlttlttsnNtdlrIrrvulttetnrLInIlryopbdands tnooaN.d <br />,d N. ta date find platy and due toOo °Oua.(e stets, (MBtrtin Std '11110) <br />CERTIFIES <br />AND <br />