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1. DECEDENTS -NAME (First, Middle, Lest, Suffix)
<br />• Frances D. Lorenzen.
<br />2. SEX '`;!
<br />Female
<br />3. DATE F D j (ht at-Yr.)
<br />October 11, 2010
<br />4. CITY AND STATE OR TERITORY, OR FOREIGN COUNTRY OF BIRTH
<br />kr . r 'r
<br />North Loup, NE
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />. • . 82 .
<br />55 UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />• August 16, 1928
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />i q s - • 7. SOCIAL SECURITY NUMBER • - , •
<br />507- 324088:
<br />ea PLACE OF DEATH
<br />HOSPITAL ❑ InPallard QIyEB:' gNureing Home/LTC 0 Hospice Fadxly
<br />, 0 ER/Outpatient 0 Decedent's Home
<br />O DOA O Other (Specify)
<br />r - 8b. FACILITY -NAME (Snot Inslltullon, give street and number)
<br />,a
<br />Wedgwood Care Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />a! Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />I 9a RESIDENCE -STATE
<br />rka Nebraska
<br />9b. COUNTY
<br />Hall
<br />9a CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />7503 S. Monitor Rd.
<br />Be. APT. NO
<br />9f. ZIP CODE
<br />68803
<br />96 INSIDE CITY LIMITS
<br />0 YES g NO
<br />10a. MARITAL STATUS AT TIME OF DEATH U Manied0 Never Married
<br />:.. # 0 Married, but separated U Widowed I1 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, LasL Suffix) I wife, give maiden name.
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />ttI
<br />k r Rex Larkin
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Alma Cox
<br />i -` ; 13. EVER IN U.S. ARMED FORCES? Give dabs of sante8yea
<br />(Yes, no, or unk.) No
<br />14e. INFORMANT-NAME
<br />Lawrence Lorenzen
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />15. METHOD OF DISPOSITION
<br />� �
<br />0 Burial. 01 Li Donation
<br />q'r iif Cremation , Entombment
<br />L.) Removal 0 Other (Specify)
<br />1§a..€ MBALMER TU
<br />! w
<br />7� � %AE ( 4 2 , tier b L
<br />lab. LICENSE NO.
<br />x ' •
<br />16c. DATE (Mo., Day, Yr.)
<br />October 11, 2010
<br />1 . CBME7EFtY . CREMATORY OR OTHER LOCATION CITY f TOWN STATE
<br />Central Ne. Cremation Ser,• Gibbon • .Nebraska
<br />17a FUNERAL HOME NAME AND MAILING ADDRESS
<br />1 Godberson Mortuary P.O. Box 10 Gibbon,
<br />E. ., _ ;,, 4,. jr::;E3 i , c .tee . �. 'A:i
<br />18. PART I. Enter We magma -diseases, inludett, or complcations-lhat
<br />respiratory anest or VEMInctilerlaffillation a8houl showing the otology.
<br />IMMEDI TE CAUSE:
<br />BdMEDIATE CAUSE (Final ,(, (e)
<br />(Street, City c Town, Slate
<br />Nebraska
<br />F ska { l 4 5, 1
<br />'�,L.S?�A;� 1. 4 ^ ".S d a 4•q 4dt-l.L'T.r . ... /•'h r t .r, r--� x Y
<br />directly caused the death. DO NOT enter terminal events such as cardiac wrest, APPROXIMATE
<br />DO NOTA80REVIATE Enter clay one cause on a Ste. Add additional Ines inecetsary.
<br />�r onset
<br />17ti: DP Code'
<br />68840
<br />( ,
<br />INTERVAL
<br />to death
<br />, �
<br />disease or condition resulting =j
<br />Indealhf DUE TO, OR C EQUE CE OF:
<br />Sequentially list condtlons,if (b) C h o - ' ` - -- <*e �.hl �¢�--'�
<br />any. leading to the cause baled
<br />' onset to death
<br />L. C Qrt l+lo
<br />r
<br />`,. online a. DUE TO, OR = A CONSEQ ENCE OF: • onset to death
<br />Eder the UNDERLYING CAUSE
<br />(disease or NJwythatin5ated (c ) 4 • (
<br />te awdsresaltlngadeath) t W w
<br />∎. ,
<br />' pp LAST DUE 70, OR AS A •' •,• EQUENCE OF: ; onset to death l
<br />(d)
<br />18. PART . OTHER SIGNIFICANT CONDITIONS- CandiUons contributing
<br />111
<br />to the death but not resyhfng In the underlying
<br />.- . ' % ....°`"" l
<br />cause given In PART I.
<br />'
<br />19. WAS MEDICAL EXAMINER
<br />- OR CORONER CONTACTED? •
<br />OYES �NO
<br />..
<br />�- - 201FFEMALE: -
<br />�.] Not Pregnant within pest year •
<br />L Pregnant atemeotdeath • •_
<br />kt U Nei Pregnant, but pregnant within 42 days of death
<br />0 Not Pregnant but pregnant 43 days to 1 year before death
<br />0 Unknown If pregnant within the pest yew
<br />Zia"' NEROF ,,p H
<br />Nahra H • cle
<br />'- l O icicle
<br />.0AcddentU.Pendtnginvealigatlon
<br />0 Suicide 0 Could not be determined
<br />21b,IFTRAN RTATIONINJURY"
<br />O Driver/Opeiataor
<br />0 Passenger
<br />I) Pedestrian
<br />0 Other (Specify)
<br />`21aWA5AN AUTOPSY PERFARMED?'
<br />• '
<br />OYES NO
<br />2t t WERE AUTOPSY FINDINGS *MAKE TO
<br />COMPLETE CAUSE of DEATH?
<br />0 YES `C1 NO
<br />"' 22.. DATE OF INJURY (Mo., Day, Yr.)
<br />a+ { ;
<br />22b. TIME OF
<br />INJURY
<br />m
<br />22c. PLACE OF INJURY -Al home,
<br />farm, street, factory, office building, constnctIon elle, efc. (Specify)
<br />t -! 22d. INJURY AT WORK?
<br />ei 0 YES la NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ., ZIP CODE
<br />2Qa DATE OF DEATH (Mo., Day, Yr.)
<br />(QT 1 /, ' /O
<br />lf
<br />7t
<br />24a. DATE SIGNED (Mo., Day, Yr)
<br />24b. TIME OF DEATH
<br />m
<br />23b. DATE SIGNED ., Day, Yr.)
<br />)t. I o/ r t /0
<br />23c. TIME OF DEATH
<br />k 1574P1
<br />246 PRONOUNCED DEAD (Mo. Day,Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />Di
<br />23d.Tothe c( ge death occuredst thedme dab D $ r �
<br />and due b Ike ousels) stated gavel= and Title) ) e U
<br />24aOn8rbaebofexambatlonandbr inmy opkdoedesthoccenedat
<br />the 8me, dime and place and due b the ireise(s) stated. (Signature and Ills) 1 .'
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />' 0 YES J NO 0 PROBABLY Rid UNKNOWN
<br />28a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES I NO
<br />26b. WAS CONSENT GRANTED?
<br />..Not Applicable if 28a Re NO L I YES,,10
<br />27. NAME. TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONER'S PHYSICIAN OI;COUNTY ATTORNEY) (Type or Print)
<br />W.J. Landis, MD 2444 W: Faidrey Av: ' Grand'Islaild,NE'68803 • •
<br />28e. REGISTRAR'S SIGNATURE
<br />I 295. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />I . 00T 14 2010
<br />DATE OF ISSUANCE
<br />FEB 12 2015
<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 NEDRASKApePAR pF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VI1 L sc,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />,S 4LV S , : COQR
<br />A SSSTAIVT.- E STATE EG $TRARi
<br />D,E �'ME401 P .TH A 46,' ,
<br />H(/MA f' SERVI
<br />HHS-81 11103 (55081)
<br />
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