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STATE OF NEBRASKA 201603439
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANDt.{I'�UMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAS-L3EPAR7to1NN.T OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR 1 ALd C)'Rl, .S. ^,
<br />i
<br />DATE OF ISSUANCE
<br />01/03/2013
<br />LINCOLN, NEBRASKA
<br />1. DECEDENT'S -NAME (First,
<br />ICennetll
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />toddle. Lett „. 8.01*) 'JI2. SEX 3. DATE Of DEATH (Mo., Day, Yr.)
<br />Ray'' Freeman ! Male Deter 26. 2012
<br />4. CITY AND STATE ORTERRITORY, OR FOREIGN COUNTRY OF BIRTH 5e, AGE4aet twiggy 50. UNDER 1 YEAR 5c. UNDER 1 DAY 6: DATE OF BIRTH :(Ma, Day, Yr.)
<br />MOS. : DAYS :HOURS MINS
<br />Burwell, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-64-7765
<br />FACILITYYNAME (If not Instlnr6on,:ptve: street and !lumber)
<br />5251 W. Guenther Road
<br />: - . Sc. CITY OR :TOWN OF DEATH (Include ZIP Cade)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE 96. COUNTY
<br />Nebraska 1 Hall
<br />9d. STREET AND NUMBER
<br />612 Linden Avenue
<br />10a. MARITAL: STATUS AT TIME OF DEATH ( t4errted 0 Never Married
<br />0 Married, Inn *panted 0 Widowed Divorced 0 Unknown
<br />11.FATHEWS44AME (First, Meddle,
<br />JI 15. EVER 1N U.S. ARMED FORCES? 131.. dates of Senip: S:yes.
<br />(Yee,e or unk.)
<br />5. METHOD OF DISPOSITION
<br />0 Burial O Donation
<br />q[crs axon O Enkembmunt
<br />O Removal O Other (Snuffy)
<br />17s. FUNERAL HOME NAME AND MMISANG ADDRESS (Street, Ciy or
<br />Peters Funeral Home Inc. P.O. Box
<br />IMMEDIATE CAUSE (Final
<br />Gesso or eomildonrat+ling
<br />In death)
<br />liscluentsily 9Mcondition,
<br />N. leerSrg:lathe saute
<br />bled o6 lint it.
<br />.:.
<br />Inlet Ow UNDERLYING ': 01
<br />CAUSE (dtewear5491%%Nt. DUE TO, .QRASACONSEOUENCE OF:
<br />: '.
<br />inlaid* We events resulting
<br />In dntlt)LAST
<br />20. IF FEMALE:
<br />0 Not pregnant *thin put year
<br />0 Pragnent et dmeol deed)
<br />O Not pregnant, but migrant within 42 days of
<br />O N0l pregnant, but pregnant 43 *yet 1 year before doss
<br />0 Unknown if pregneM within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK ?
<br />!(]
<br />YES 13 NO
<br />(b)
<br />DUE TO, OR AS A C
<br />23a. DATE OF DEATH (Mo.
<br />23b. DATE
<br />DUE TO, IOR
<br />(d) ;;,>
<br />12
<br />Central Nebraska
<br />A CONSEQUENCE OF:
<br />SEQUENCE OF:
<br />220. TIME OF INJURY
<br />m
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET 5. NUMBER, APT. 90.
<br />23d.To the otiet of my knowledge, death occurred at the time, date and plea
<br />end doe to the caua o(s) slated.: (Signature en4TiI -) 7
<br />.3'1nti_ /
<br />25. DID TOBACCO USE C0*rRIBUTE TOTHE DEATH?
<br />0 YES , O NO 0 PROBABLY SCUNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CE (ER (type or PtIn
<br />oenc o ( t,t-NKte
<br />25a. REGISTRAR'S SIGNATUR
<br />(Yea.)
<br />64
<br />100. NAME OF SPOUSE >(Fkst,
<br />Carol V. Hansen
<br />Suffix
<br />14a. INFORMANT -NAME
<br />Carol V. Freeman
<br />160. EMBALMER-SIGNATURE
<br />None - Direct cremation
<br />15d. CEMETERY,: CREMATORY OR OTHER LOCATION :.
<br />Cremation
<br />181 St.
<br />15. PART 1.:Enter tM chabudittokk-dNeases, Injuries. or wnpecatone- -hid Grotty caused to death. D0 NOT en* *mil W events wch u*Wino arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enterony one souse on a line. Add additlonel Anse M neceeeary.
<br />IMMEDIATE CAUSE: :' I onset to death
<br />1Q V II(Cilrt IGd Zvi nfCkiO
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS- Condhiore contributing to the dealO but not resulting m tin underyingause given in PART M
<br />211. ER OF DEATH
<br />Wrsl 0 Homicide
<br />O AaMent O Pending bmadystion
<br />O SWelde 0 Could not be determined
<br />CSTYIIWN
<br />23c. TIME OF DoEI�
<br />r (gs‘25 CZsm
<br />SL PLACE OF DEATH
<br />fi EM: C1 InpMNnf QTI(EB:I' 0 NurPig Home/LTC 0 Hoepke Fad
<br />0 ERfOugetNm O Dewdm(1 Horne
<br />22c. PUCE OF INJURYAI home, fa
<br />G) DOA
<br />CITY OR TOWN
<br />Grand Island
<br />12. MOTHER'S-NAME (First,
<br />1 180. LICENSE NO
<br />Servi
<br />1
<br />CITY /TOWN 'f
<br />10. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />O
<br />Passenger
<br />O Pedestren
<br />0 Other (Specify)
<br />28a. HAS ORGANOR TISSUE DONATION BEEN CONSIDMED?
<br />OYES 'NO
<br />4- t \u1) C.J, P1 irk 4.
<br />84.000NTY OF. DEATH
<br />Hall
<br />STAN1,EY S COOPER
<br />ASMI5TA TT REGIST k
<br />OEAARtTM �E
<br />HU1�N`SERV.
<br />9e. APT. NO 91. ZIP CODE 9g. INSIDE CITY LIMITS
<br />68801 N YES 0 NO
<br />Last. Su0kt) 11.lki, give maiden name.
<br />1_i R
<br />street, factory, office building, conNructlan NW etc. (Spedy)
<br />Q�
<br />M
<br />sow ($peay) -�
<br />w43Tkp a.,=
<br />210. WAS AN AUTOPSY PERFORMED?
<br />O YES. '9(110 g.
<br />lid. WERE AUTOPSY FINDINGS: AVAILABLE TO
<br />COMPLETE CAUSE OF DEATN4
<br />O YES 0NO
<br />STATE ZIP CODE
<br />. On basin bf sxendadbn and/or Investigation, : N my opinion death occurred at
<br />the dme, date and plea and due to the ousels) staked. (SlpnaNte &05 TJIe )T
<br />Mb. . WAS CONSENT GRANTED?
<br />Net r h, 428a Is no OYES ONO
<br />3 tTL ;♦. 6
<br />,/ .l c(.3s11- G 1VE
<br />250. t1ATE FILED BY. REGISTRAR (Mo., DWG Yr.)
<br />DE
<br />1
<br />C 312012
<br />12 3
<br />June 28, 1
<br />I wet to dat
<br />948
<br />Malden Surname)
<br />.TnhnaOY)
<br />141: RELATIONSHIP TO DECEDENT
<br />Wife
<br />IBC. DATE (Mo., Day, Yr. )
<br />Laoalter 27, 2012
<br />STATE I'
<br />Gibbon, Nebraska
<br />17 1. Zlp Code
<br />APPRf XIMLITE:INTERVAL
<br />5,e ca )n
<br />onset to death
<br />I
<br />1 onset to death
<br />24b.TIMI5 OF DEATH
<br />"414S ALM
<br />0196
<br />It WAS MEDICAL EXAMSINER
<br />CORONER CONTACTED?
<br />24d. TAME PRONOUNCED DEAD
<br />: Z5 GUMS
<br />HHS-61 Rev. 4/12;(56061
<br />
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