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1. DECEDENTS -NAME (First, Middle, Last, Suffix) •
<br />Lori Jo Olesen
<br />2. SEX
<br />Female
<br />A DATE OF DEATH (Mo,Day,Yr.)
<br />April 10, 2009
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />6a. AGE -Last Birthday
<br />(The.)
<br />55
<br />6b. UNDER 1 YEAR
<br />6c. UNDER 1 DAY
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />October 3, 1953
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />- - 50 5-74 - 5 0 8 8
<br />- 8a. PLACE OF DEATH
<br />KinarAn- MI Inpatl.nt QEUEa& ❑ Nursing Home/LTC ❑ Hospice FaciNty
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />❑ DOA ❑o"re`(Spao"")
<br />Bb. FACLTY -NAME (I not katltutlon, gIve street and number)
<br />Saint Francis Medical Center
<br />Bo. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803 ,
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1217 West Division Street
<br />9e. APT. NO.
<br />9L ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />®Y•s ❑ No
<br />10a. MARITAL STATUS AT TIME bF DEATH ® Marled ❑ Never Marled
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown .
<br />101 NAME OF SPOUSE
<br />Roger Geo
<br />(First, Middle, Last, Suffix) if wife, slue maiden name.
<br />... .r _ • . _.,
<br />Olesen - - _ .. -- .. _. .
<br />11. FATHER'S -NAME (First, Middle, Last, 841E4
<br />Neale Melvin Wells
<br />11 MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Carol Ann Uebsack
<br />13. EVER IN U.S ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unit.) No
<br />14e. INFORMANT -NAME
<br />Roger George Olesen
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16. METHOD OF DISPOSITION
<br />El Burial ['Donation
<br />® Cian.lion ['Entombment
<br />DR., ❑oMgap.ciiy
<br />16a. EMBALMER - SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />April 13, 2009
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITYROWN STATE
<br />Central Nebraska Cremation Service Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND SWUNG ADDRESS (Street, City or Town, Stare)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />U. PART L Ether the chab.rewu,tr . Names, or complications- that directly awed the death. DO NOT entrMrndnel everts such as cardiac amt, APPROXIMATE INTERVAL
<br />..phatory arrest, orwntACUW fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter o,y one cause on a Anne. Add additional lire, If necessary.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final
<br />disease or Donation resulting a) 4:� S - At +w.ls
<br />h death)
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Sequentially list condltlons, H in f 1 / .+- P o °a � j S
<br />any, leading to the awe listed Get r' t c • ts -
<br />on Min. a. DUE TO, OR AS A CONSEQU NCE OF: onset to death
<br />Enter the UNDERLYING CAUSE C) A-fG d h J A s m. / 1 1 c "�`1's
<br />h '7`�f .�
<br />(disease a Injury that initiated
<br />t h e mine minima in death) DUE TO, OR AS A CONSEQUENCE OF: • onset to death
<br />LAST
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDmONS.Conditlanns contributing to the death but not snuffing In dm underlying cause given In PART L
<br />CU f U / sec. /+ ta6t1-e
<br />19. WAS MEDICAL. EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ONO
<br />_25 IF FEMALE:
<br />Not pregnant within past year
<br />0 Pregnant *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 />❑Unkrawn If pregnant within the put year
<br />21e MANNER OF DEATH
<br />Natural ❑ Homicide
<br />b Ae Ident ❑ Pending MvutigatIon
<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 .00
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ No
<br />22.. DATE OF INJURY (Mo., Day, Yr.)
<br />221 TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, fans, street, factory, office building, conskuetlon site, eta (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22L LOCATION OF INJURY - STREET i NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />tg
<br />w
<br />3 az
<br />e .
<br />a e
<br />00
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 10, 2009
<br />kli
<br />y 0
<br />I
<br />as o
<br />8
<br />2 g
<br />1 Cg 8
<br />8 O
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />23b. DATE SIGNED (Mo, Day, Yr.)
<br />VJ/ ./
<br />23c. TIME OF DEATH
<br />1: 56 D m
<br />24e. On Me basis of examination andlor investigation, In my opinion death ocaered
<br />at the time, date and place and due to the causes) stated. (Signature and Title)
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to ) stated. (Signature and Title)
<br />44 40
<br />26. DID TOBACCO USE NTRIBUTE TO THE DEATH?
<br />13 NO ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR BEEN CONSIDERED?
<br />❑ YES
<br />26b. WAS CONSENT.GRANTED?
<br />Not AppOwld. S 28a Is NO ❑ YE9 ❑ NO
<br />27. YES
<br />AME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN ATTORNEY) (Type or Paint)
<br />Jay Anderson, MD, 729 N. Custer Ave:, Is1an
<br />. Nehraska FRRf)R
<br />2l)a: REGISTRARS SIGNATURE
<br />47,tj , S.. 610firt;
<br />26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />APR 1 6 2009
<br />DATE OF ISSUANCE
<br />LINCOLN, NEBRASKA
<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.
<br />JUL 1 12oi4 201405349
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN•SERinCES
<br />STANLEY S..CQOPER
<br />A.SSIST4N7 STATE REOI$TkAR
<br />DEPAR AND
<br />HUMAN . E'Ri/ICE'Si
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<br />n330
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