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<br /> WHEN TI�NS COPY CAR�ES TFIE RA/SED SEAL OF THE NEBRASKA HEALTH AAli2ltWNAN SERVICES
<br /> SYSTEM,IT CERTIF/ES THE BELOW TO BE A TRUE COPY OF THE ORIGINl���O�D_9htf/EE WITH
<br /> THE NEBRASKA HEALTH AND HUMAN SERV/CES SYSTEM,V/TAL S�3 SE��AIIiICH IS w
<br /> THE LEQAL DEPOS/TORY FOR VITAL RECORDS ' _ - �
<br /> DATE OF/SSUANCE _ :� �� .
<br /> _
<br /> -� �� _ �I�PER
<br /> DEC 2 1999 20000080� _ -
<br /> �.81$��NT_$TA��I�AR
<br /> LINCOLN,NEBRASKA HEALTH�AID�N SER�IL�ES S�JEM . �
<br /> _ - �;_ �;.�,
<br /> STATE OF NEBRASKA-DEPARTMENP OF HEALTH AND HUIN�$�R�,4 FtidA�AND SUPPORT Z
<br /> V1TAL STATISTICS �,..�-�.�= ,,
<br /> CERTIFICATE OF DEATH � �
<br /> t.DECEDENT�NAME FIRST MIDDLE LAST 2.SEX 3.DATE OF DEATH /Monrh Day Year)
<br /> Richard Wa e Samuelson Male November 12, 1999 �
<br /> C.CITV AND STATE OF BIRTM lll nof in U S.A..neme caunhy/ 58.AGE-Lsl�Bir�hOay UNDER 1 VEAR UNDER 1 DAV 6.DATE OF BIRTH /Monlh.Day VearJ
<br /> Milford, Nebraska '""76 Sb MOS I oA�s SC.HOUFlS' MINS ��OUCL 23, 1923 �
<br /> 7.SOCIAL SECURTIY NUMBEP Ba.PLACE OF DEATH
<br /> � 5OH-IH-2269 HOSPITAL: � InpaGent OTHER: � Nursing Home ,
<br /> BD.FACILITY-Name /Hrrol msfitulion,y'rve shee7 and numbsr) � Efi Oulpetient � Rasidence �
<br /> St. Francis Memorial Health Center ❑ °OA ❑ a"e�,s�,ti� .�
<br /> • Bc CITV.TOWN OR LOCATION OF OEATH .BC.INSIDE CITV LIMITS Be.COUNTV OF DEATH �4/J
<br /> Grand Island, Vea X� Na ❑ Hall �
<br /> 9a.RES�Nebraska 9e couNHdll. � cGrandR Island � SO�I N�" .MBPhoenix c� 68801 9B Y e1D�TNofM�❑ a
<br /> C7 1 �
<br /> 10.PACE-�e.g.,White.Black.Amaricen Intliaa 11.ANCESTRV le.q..141iln.Maxicen,Oxmen,alc� 12.�MARRIED ❑WIDOWED 13.NAME OF SPOUSE lll wAe.give meiQen neme� p �
<br /> etc.115peciy�r,�lte �5���� p,merican NEVER DNORCED Orva Burnell Gjerde ��
<br /> ����
<br /> 14a.USUAL OCCUPATION /G�ve kinOd work dons Ouring mosl tlb.KIND OF BUSINESS INOUSTRV 15.EDUCATION �Speary only highest grade completed) �,�,
<br /> ol working li/e,evBn il relvBdl Elementa r contlar 10�12� ol
<br /> Whole Drug Salesman Pharmaceuticals "f�° Y r� �ee�'.'°`5•� °
<br /> • 18.FATHER-NAME FIRST MIDOLE UST 17.MOTHEH FIRST MIDDIE MAIDEN SUFNAME ��
<br /> Richard B. Samuelson Jessie Moorberg
<br /> 18.WAS DECEASED'eV'eRIN US.ARMED FORCES? 19a.INFORMAVT-NAME v
<br /> (Ves.no.or unk.� lit yes.grve war ano oates ol earvices;
<br /> Yes; II 11-23-42 1-23-�6 Orva B. Samuelson �
<br /> 19b.INFORMANT MAILING ADDRESS ISTREET OR R.F.D.NO..CITV OFi TOWN.STATE.21P�
<br /> 811 :E. P enix Grand Tsland, Ne. 68801 ��
<br /> - J
<br /> 20.E MER-SIGN URE 6 Li NO. 21a.METHOD OF OISPOSITION 21b.DATE 21c.CEMETERV OR CREMATC9V NAME . tp
<br /> v V
<br /> �euriei ClRemo•:a� NOV. 1'rJ, 1999 Lincoln Memorial Park __ �
<br /> a.FUNERAL HOME- E 21d.CEMETERV OR CaEMA70Av LOCATION CI7V OA TOWN STATE
<br /> Apfel-Butler-Geddes ❑Cremanon ❑oo�a„� Lincoln,� Nebraska '�
<br /> 22t.FUNERAL tiOME ADDRESS fSTREET OR R.F.D.NO_CITV OR TOWN.STATE,ZIP)
<br /> 1123 West Second, Grand Island, NE 68801 v
<br /> 23. IMMEDIATE CAUSE IENTER ONLY ONE CAUSE PER LINE FOR IaL Ib�.AND(cp I Interval between onsel antl aeam
<br /> PART �
<br /> ' �a� - �.ESP�RA-roR4 F,�_i�uRE �7�0 wfFlct _ �
<br /> � D TO.OR AS A CONSEOUENCE OF � Interval between onsei antl Jeam
<br /> �bi M��r�Tt G �-u N GANC.�R � E-�-- �r' - 1`
<br /> DUE T0.OR AS A CONSEOUENCE OF�. � Interval betvreen onset ane Ceam
<br /> I ��
<br /> Icl I Q
<br /> OTHER SIG::IFICANT CONDITIONS�Cor+Gitio�s contnCuling to iBe Eeath bul not rNatetl PART III IF FEMALE.WAS THERE A 2a AUTOPSV 25.WAS CASE REFERREO TO MEDICAL Q
<br /> PART PREGNANCY IN TME PAST 3 MONTHS� EXAMINER OR CORONER� �
<br /> II
<br /> �Ages 10-54) ves No ves No ves No
<br /> 26a. 26b DATE OF INJURY /Mo..Day.Yc) 26c.HOUR OF INJURV 26d.DESCRIBE HOW INJURv OCCURRED �
<br /> � Accident � UnOeterm�ned M �
<br /> \ � Swcitle � Pending 26e.INJURY AT WORK 261.PLACE OF,�JURY([�1�t.larm,street.factOry 26g.LOCATION STREET OR R.F.D.NO. C�TV OR TOWN � STATE
<br /> � ❑ ❑ ❑ offCe buildi eta Spec �
<br /> Homicitle Inves��gauon Yes NO
<br /> , 27a.DATE OF DEATH /Mo..Day.YcJ 28a.OATE SIGNED /Mo..Day Yr.l 2BD.TIME OF DEATH _. �
<br /> / z �c �g= (f�17�9°� � �'
<br /> • $u`�'i 27G.DATE SIGN D lMo.Day.Yc1 27a TIME OF DEATH �g��28c.PRONOUNCED OEAD /Mo.Day,Yc/ 28d.PRONOUNCED DEAD (Hou�l �
<br /> �t� 6�
<br /> g � I �'� �� M x W�� M �
<br /> '� 270.To the DpSt 0�my krlpwletlge.tleeM OCLurrBA et MM tlrtM,Ae�B�ntl WeCB�ntl due M MB ��c> 28e.On ihe Oasis W ezaminatwn anC�or investiqaUon,in my opnion tleath occunetl at
<br /> causelsl stated. � � a the time.tlate and place and tlue to the cause�s�stated. �
<br /> �5 naNre anG TiUe► � S naWra and TNe
<br /> 29.DID TOBACCO USE CONTRIBUTE TO THE DEATH? 3Qa HAS OR6AN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? �
<br /> � YES � NO � UNKNOWN � YES �NO � VES �NO V�
<br /> 3t.NAME AND AODRESS OF CERTIFIFA IPHV&GAN,CARONER'S PHYSICIAN OR CWNTY ATTORNEY� lTypeaPrinp � �
<br /> Peter Ledakis M.D. 2116 W. Faidle Ave. , Grand Island, NE. 68803 �''�"
<br /> 32a.REGISTRAH 32D.DATE FILED 8V REl31STMH /A10..�y.Yr./
<br /> . NOV 2 2 1999
<br />
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