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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL, TH A
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA, I(A`
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FO' � T/�L'•.l�
<br />DATE OF ISSUANCE
<br />LIAR 14,2014
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />n5F !'NLEYi:
<br />,ASST
<br />1re
<br />'111 IAN SERVICE
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERC
<br />201 402001
<br />At' S$RVIC €S, IT CERTIFIES
<br />f�ll)I F HEALTH AND
<br />J
<br />P
<br />N 1. DECEDENTS -NAME (First, Middle, Lut, SufIx)
<br />Harold Oscar Nielsen
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Litchfield, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />520 - 504279
<br />8b. FACILITY-NAME (it not Institution, give strut and numbsr)
<br />Madonna Rehabilitation Hospital LTC
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Lincoln 68506
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />4136 Mason Ave
<br />10a. MARITAL STATUS AT TIME OF DEATH I Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S •NAME (First, Middle, Last, Suffix)
<br />Harold Hans Nielsen
<br />13. EVER IN U.S. ARMED FORCES? Give dabs of service N Yes.
<br />(Yes No, or Unk.) Yes 06114/1965
<br />15. METHOD OF DISPOSITION
<br />El Burial ❑Donoaon
<br />❑Cremation ❑Entombment
<br />❑ Removal ❑Othe,(Spuiy)
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Roper & Sons, Inc., 4300 0 Street, Lincoln, Nebraska for
<br />All Faiths Funeral Horne, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See Instructions and examples)
<br />1e. PART 1. Enter the Onaa1 erewnte • dimness, Wades, or complications that directly owned the death. DO NOT War Weenie wants such ss mediae mete,
<br />respiratory e,ut. or venblculenbdRetten without Wowing the Woloay. DO NOT ABBREVIATE. Enter only one wow one Ow. Add addltlond lines It nowaauy.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting e) R p
<br />In death)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />onset to death
<br />Sequentially list Conditions, d
<br />b )
<br />any, leading to the cause listed
<br />on line a.
<br />Enter the UNDERLYING CAUSE c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />onset to death
<br />(dismiss or Injury that Initiated
<br />the avant* resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />onset to death
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS•Condltions contributing to the death but not resulting In the underlying cause given In PART 1.
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<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 N pregnant within the put year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />CITY/TOWN
<br />STATE 21P CODE
<br />286. REGISTRAR'S SIGNATURE
<br />9b. COUNTY
<br />Hall
<br />16a. EMB ME IG TUR
<br />22b. TIME OF INJURY
<br />- CJ
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />, YES ❑ NO ❑ PROBABLY ❑ UNKNOWN
<br />CERTIFICATE OF DEATH
<br />6s. AGE -Last Birthday
<br />(Yr.)
<br />82
<br />88. UNDER 1 YEAR
<br />MOS. DAYS
<br />21a. MANNER OF DEATH
<br />SeNatunl ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Sulcide ❑ Could not be determined
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 22, 2009
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />April 24, 2009 9:45 am
<br />23d. To the best of my know
<br />du to thew Signature and at the Ms) dims, d and place
<br />and d
<br />�(9/
<br />/ 94/01
<br />h 3
<br />2. SEX
<br />Male
<br />8c. UNDER t DAY
<br />HOURS MINS.
<br />"3 D4TE OF DEAh4MO.,Day,Yr.)
<br />April 22, 2009
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />September 28, 1946
<br />8a. PLACE OF DEATH
<br />HOSPITAL: ❑ Inpatient
<br />❑ ER/Outpatlent
<br />❑ DOA
<br />comp; Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other(SpecIfy)
<br />❑ Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9s. APT. N0.
<br />9f. ZIP CODE
<br />68803
<br />146. INFORMANT -NAME
<br />Dianna Jo Nielsen
<br />16b. LICENSE N0.
<br />f 4 T(2,
<br />218. IF TRANSPORTATION INJURY
<br />❑ DrIverlOperator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />%YES ❑ NO
<br />APR 2 8 2009
<br />9g. INSIDE CITY LIMITS
<br />El Yes El No
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, ghre madden name.
<br />Dianna Jo Denman
<br />12. MOTHER'S -NAME (First, Middle,
<br />Dorothy Senff
<br />Maiden Surname)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16c. DATE (Mo., Day, Yr.)
<br />April 25, 2009
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />CITY/TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68510
<br />68801
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES a NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YEs (No
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH ?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, fare, street, factory, office building, construction site. stc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />24b. 111,1E OF DEATH
<br />m
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />24e. On the basis of examination and/or Investigation, In my opinion death occurred
<br />et the tine, data and place and due to the cause(s) stated. (Signatu• and Title)
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable. If 20a is NO ❑ YES NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />D.C. St jwn S mi n )C 01 Pi nom Taktm Rri Sri Fos 7211 TA nrr1 r` NP f,RR1
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />1
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