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1. DECEDENTS -NAME (First, Middle, Leek - -- Suffix)
<br />Norma Jean Simonson
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />-y 8, 2014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />St. Libory, Nebraska
<br />St. AGE-Last Birthday
<br />(Yrs.)
<br />82
<br />Sb. UNDER
<br />MOS. >,
<br />1 YEAR ::SC.
<br />DAYS
<br />UNDER
<br />"HOURS
<br />T DAY
<br />'MINE.
<br />8 DATE OP BIRTH (Mo., Day, Yr.)
<br />November 1, 1931
<br />7. SOCIAL SECURITY NUMBER
<br />243 -50 -8446
<br />Se. PLACE OF DEATH
<br />imam.: X) inpatient QTHEt3' ❑ Nursing HomeLTC 0 Hospice Fae9ny
<br />❑ ERIOWpathnt 0 Decedent's Horne
<br />0 DDA 0 Omer (Speedy)
<br />fib. FACILITY -NAME (If not Institution, give street end number)
<br />Howard ` County Medical Center
<br />Se CITY OR TOWN OF DEATH (Include Z(p Code)
<br />St. Paul 68873
<br />8d. COUNTY OF DEATH
<br />Howard
<br />9a. RESIDENCE•STATE
<br />Nebraska
<br />9b. COUNTY
<br />Merrick
<br />Sc . CITY OR TOWN
<br />St. Libory
<br />9d. STREET AND NUMBER ''
<br />1858 Worms Road
<br />9e. APT NO
<br />91. ZIP CODE :
<br />68872
<br />9g. INSIDE CITY LIMITS
<br />O YES g@ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH O Married 0 Never Married
<br />0 Maenad, but separated RiMdowed ❑ Divorced < !Unknown
<br />10b. NAME OF SPOUSE (First Middle, Last, Suffx) If wife, give maiden na '.
<br />John M. Simonson (Deceased)
<br />11. FATHER'S -NAME (Firs,: Middle Last, Suffix)
<br />Albert Jacob Simonson
<br />:12. MOTHERS -NAME (First, Middle,:: :. Maiden. Surname)
<br />Milda Amelia Dickman
<br />13. EVER IN Us. ARMED FORCES? Give dates of eervbe E yes.
<br />(Yes, no, W urdi:) No
<br />14a: INFORMANT -NAME
<br />Jerry J. Simonson
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />16. METHOD OF DISPOSITION
<br />�CBurial ❑ Donation
<br />180. EMBALMER- SIGNATU
<br />f6r1L . ki o
<br />.C METERY,
<br />18b. LICENSE NO.
<br />1078
<br />1&. DATE Oho., Day, Yr,) a
<br />May 12, 2014
<br />O Cremation 0 Entombment
<br />O Removal 0 Other (Specify)
<br />16 CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Norwegian Cemetery St. Libory, Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or .Town, State/ !;
<br />Peters Funeral Home Inc. P.O. Box 181 St. Paul NE
<br />�t p. PART I. Enter the chain of events - diseases, uyuries, or complications -that directly caused the death. DO NOT antes terminal wants such as cardiac arrest, APPROXIMATE
<br />I
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary: I
<br />IML : - +a1M¢M;lti
<br />IMMEDIATE CAUSE '' 4
<br />17b. Zip Code
<br />INTERVAL
<br />death
<br />(Faro4
<br />diem or wrldl9on,,,mon0 DU ((�� (p et to
<br />In death)
<br />r Ill / J�li �i 1 i LLli Jr T /'�i a: A...J
<br />.r
<br />Sequentisly
<br />DUE T0, OR AS A CS it I onset death
<br />AC ON S EQUENCE OF:
<br />lined ofl One e.
<br />Enter the UNDERLYING (c) I
<br />CAUSE
<br />Malted
<br />In
<br />(dfwee or Injary t at DUE TO OR AS A CONSEQUENCE OF: I onset to death
<br />Bra events laautting I
<br />death) LAST I (d)
<br />Ate .PA RT II, OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not restilting in the anderiying cause given in PART I.
<br />r//mie. Okhste, L/ 49 ll 'Rr -
<br />_J
<br />i9 {V MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES m'fJ0
<br />FEMALE
<br />Not pregnant within pas year
<br />U Pregnant at time of death
<br />death
<br />0 Not pregnant but pregnant within 42 days of dea
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown iflpregnent within the past year
<br />I. M R 0 DEATH
<br />�t4atural 0 Homicide
<br />0 Accident° Pending Investigation
<br />O:SuiCld. O Could not be determined
<br />2Ib. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Passenger
<br />Pedestrian
<br />O Omer (Specify)
<br />WAS AN AUTOPSY PERFORM ED?
<br />0 YES
<br />2 1d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />0 YES ONO
<br />22e DATE OF INJURY (Mu, Day, Yr.)
<br />22b. TIME OF INJURY >>.
<br />m
<br />22c. PLACE OF INJURY-At home, farm, street, factory, office bui ng, construction site, etc, (Specify)
<br />INJURY AT WORK?
<br />O YES O NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221 LOCATION OF INJURY. - STREET 8 NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />',9alf#r
<br />$
<br />Ida`: DATE OF DEATH Day, Yr.)
<br />S./ 0
<br />:
<br />:
<br />,. <
<br />$
<br />24a. DAT SIGNED (Mo., Day, Yr.)
<br />24h.TIME OF DEATH
<br />rn
<br />, DATE pIGNED (MO., Day, Yr.):
<br />5 3 21(1 �F:
<br />4_$t TIME OF DEATH
<br />D2 J. o P _.m,
<br />24c. PRONOUNCED DEAD ay, Yr.)
<br />DE (Mo., D
<br />24d,TIME PRONOUNCED DEAD
<br />'. . m
<br />V To of my knowledge, death ocsxredat the time, data and place
<br />- d ` to the:cause(s) stated. (Signature and The (♦ :
<br />4e. On the base of examination and/or investigation, In my opinion de41h occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title ) Y
<br />• `DID TOBAC 4y E CONTRIBUTE TO THE DEATH?
<br />YES ❑ NO 0 PRO8A8LY ❑ UNKNOWN
<br />iAS ORGAt4 OR TISSUE DONATION BEEN CONSIDERED?
<br />OriES ❑ NO
<br />WAS CONSENT GRANTED?
<br />Not Applicable If 20a Is no ' 0 YES .41
<br />NAME, TITLE AN A RESS OF CERTI IER or Print
<br />Q�� a /9 - . (, 1113 Sherman Street
<br />' 28a REGISTRARS SIGNATURE
<br />4' , , 0 1
<br />St. Paul NE 68873
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />MAY '1 4 2014
<br />STATE OF NEBRASKA
<br />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. j �
<br />tel
<br />STANLEY S COOPER
<br />ASSISTANT STATE REGISTRA
<br />DEPARTMENT OF HEALTH ANd
<br />HUMAN SERVICES
<br />DATE OF ISSUANCE
<br />05/16/2014
<br />LINCOLN, NEBRASKA
<br />201405139
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />23370
<br />
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