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1 To Be CompletedNerified by :14ERA'CTOFtECTOR - --- -- ∎ NMI ...,. rve„r NM yr si ram1 r 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Harold Oscar Nielsen 2. SEX Male 3. DATE OF DEATH (Mo.,Day,Yr.) April 22, 2009 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Litchfield, Nebraska 5a AGE -Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.) September 28, 1946 (Yrs.).. 62 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 520 -50 -4279 8a. PLACE OF DEATH HOSPITAL' ❑ inpatient Nursing Home/LTC ❑ Hospice Facility lib. FACILITY•NAME (If not Institution, give street and number) - Madonna Rehabilitation Hospital LTC 8c. CITY OR TOWN OF DEATH (Include Zlp Code) Lincoln 68506 ❑ ERJOutpatient ❑ Decedent's Home 0 DOA ❑other(speclfy) ad. COUNTY OF DEATH Lancaster 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 4136 Mason Ave 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY OMITS ® Yea ❑ No 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Dianna Jo Denman 11. FATHER'S -NAME (First, Middle, Last, Suffix) Harold Hans Nielsen 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Dorothy Senff 13. EVER IN U.S. ARMED FORCES'? 0 ve dates of service N Yes. (Yes, No, or Unk.) Yes 0611411965- 03114/1969 14a. INFORMANT -NAME Dianna Jo Nielsen 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ®eudat []Oonmeon ❑cremaaon ❑Entombment ❑itsmoval ❑Olher(Spedry) 18a EMB ME IG TORE/ •.i,(f°jJ( lair. LICENSE NO. / 401 16c. DATE (Mo., Day, Yr.) April 25, 2009 p 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State) Roper & Sons, Inc., 4300 0 Street, Lincoln, Nebraska for All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68510 68801 ' 1 Y;e'v To Be Completed by: CERTIFIER CAUSE OF DEATH (See instructions and examples) 1e. PART I. Enter as Wain ofeven(i - diseases, Inende', or complications. that directly caused the death. DO NOT enter terminal events such a. cordial east, APPROXIMATE INTERVAL respiratory meat, or ventriculw abdaaaon without showing the etiology. DO NOT ABBREVIATE, Eater only one cause on a line. Add eddmenel Knee if neceseary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final ^ p . . - r disease isease or r re condition resulting a) J ` '` / � in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially Eat conditions, ff any, leading to the cause listed b) on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or injury that initiated the events resulting in death) ' DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given In PART L 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES E NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant 111 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. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED'? ❑ YES [ NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑YES ❑ 22a. DATE OF INJURY (Mo., Day, Yr.) 122b. TIME OF INJURY 122c. PLACE OF INJURY -At home, farm, street, factory, office building, construction she, etc. (Specify) I 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY. STREET & NUMBER, APT. NO. CITY/TOWN STATE 7JP CODE A'S Is V E l- E 3 ' y e p ea a p ~ 23a. DATE OF DEATH (Mo., Day, Yr.) April 22, 2009 Z N. 11 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH m 23b. DATE SIGNED (Mo., Day, Yr.) April 24 2009 23c. TIME OF DEATH 9:45 a m O w O Z LL E w 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD m 23d. To the best of my kn • ge, tit occurred at the time, date and lace and due to the cause(: tat `Signature and Title) P tI. ■� - � Z / , Z 8 g � I2 � U U Is 24e at the time, date and place and due the g cau cause(s) my opinion death occurred se(s) titled. (Signature and TRIO 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED'? YES ❑ NO 26b. WAS CONSENT GRANTED'? Not Applicable If 26a Is NO ❑ YES A NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) �l f. ,If ,.II a e� e . - - • - 1 F eu �1 .. P I 28e. REGISTRAR'S SIGNATURE /1 �� a 'YIl1A1/ /r� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) APR 2 8 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 OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE JUN 2 4 2014 LINCOLN, NEBRASKA STATE OF NEBRASKA 201404276 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES STANLEY S.-COOPER ASSISTANT STATE REGISTRAR DEPARTMENT Of.,l EiLThh AND HUMAN SERVICES • :23t79