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200103511
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTL"ND HUMAN_SERWCES
<br />SYSTEM, IT CERTIF/ES THE BELOW TO BE A TRUE COPY OF THE ORIGMf RECbRD-0KF lE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERWCES SYSTEM, VITAL STATISTICS. SECT16K V40CH IS
<br />THE LEGAL DEPOSITORY FOR WTAL RECORDS =
<br />DATE OF ISSUANCE
<br />DEC 18 LOOO ANCEI`S'CfloPER
<br />ASSISTANT STATE REQISOtAR
<br />LINCOLN, NEBRASKA HEALTH Alib HUMAN SERwcES STEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAbISgILVICES F1NA4CESPiD SUPPORT
<br />VITAL STATISTICS
<br />_
<br />CERTIFICATE OF DEATH �= -
<br />I DECEDENT- NAME FIRST MIDDLE LAST SEX TOF DEATH - M,ini,i (,,ir Yeari
<br />I
<br />Ivan Homer Paulson Male ' December 4, 2000
<br />d. CITY AND STATE OF BIRTH ;11 hot m US A name coun(ryl Sa AGE -Last Birthday UNDER I YEAR UNDER I DAY 6 DATE OF BIRTH :Mont. Dav Y[e�ar)
<br />Hastings, Nebraska IYrsI 90 Sb MOS DAYS 5c HOURS MINIS October 5, 1710
<br />7. SOCIAL SECURTIY NUMBER
<br />9b COUNTY
<br />8a PLACE OF DEATH
<br />9c CITY. TOWN OR LOCATION
<br />--_ - "- - - - " - --
<br />506 -05 -1310
<br />Nebraska
<br />HOSPITAL
<br />-,'.I- 'L-{ Itr ',=
<br />Inpatient OTHER ® Nu,,,,, Hone
<br />8b FACILITY - Name (H not,,nstautloo, give street and number)
<br />3008 Orleans Drive �Np
<br />26. -
<br />❑
<br />ER Outpatient ❑ Res dencc
<br />Hamilton Manor
<br />PAccident Undetermined
<br />Yes
<br />❑
<br />❑
<br />DOA ❑ Othe,,S,,r,,n
<br />Bc CITY TOWN OR LOCATION OF DEATH
<br />Bd
<br />INSIDE CITY LIMITS
<br />1, COUNTY OF DEATH -
<br />— I
<br />Aurora �r., r. T! r,
<br />Aurora
<br />. i . _:_ .. *„a.. -._ ; r+•-.,.
<br />C Yes r_* Nd fF:
<br />.- '.KK.�+-�.��....+...� +e•-.,, -« _
<br />Hamilton
<br />9a RESIDENCE -STATE
<br />9b COUNTY
<br />24 AUTOPSY
<br />9c CITY. TOWN OR LOCATION
<br />PREGNANCY
<br />j 1I
<br />�( �r,�.lC. �.)'��ir l'�•
<br />90 STREET AND NUMBER dnc)ud,ng Zip L'odel 9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />-,'.I- 'L-{ Itr ',=
<br />Grand Island
<br />Yes Na
<br />3008 Orleans Drive �Np
<br />26. -
<br />266 JATEOFINJ6RY IMO Day. Yr.)
<br />26c HOUR OFINJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />PAccident Undetermined
<br />Yes
<br />❑
<br />10 RACE (a g. White. Black. American Indian
<br />11. ANCESTRY le
<br />g Italian. Mexican. German, etc)
<br />12 ❑
<br />MARRIED © WIDOWED 1 13 NAME OF SPOUSE dl wile p,ve ma, den name)
<br />etc) (Spec
<br />White
<br />IspeC�lyl _
<br />American
<br />_
<br />❑
<br />MARRIED ■ DIVORCED Marjorie Ernst
<br />MARHI
<br />14a USUAL OCCUPATION (G,ve kind of work done during most
<br />vas
<br />❑
<br />141 KIND OF BUSINESS INDUSTRY
<br />plant [ 15 EDUCATION Specify o fy highest grade completed)
<br />olworkmnlre nC�Irief
<br />f�.''
<br />No
<br />Cornhusker Army
<br />ElemP.nta,y0 S conddry id 12) College , 4or1•i
<br />Ammunitio ��
<br />16 FATHER - NAME FIRST MIDDLE
<br />LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Claude
<br />Paulson
<br />Mary Dunker
<br />18 WAS DECEASED
<br />EVER IN US. ARMED FORCES?
<br />i °
<br />19a INFORMANT NAME
<br />IYeS-11O or unk.)
<br />NN
<br />(It yes. give war and dales of servwesf
<br />28c PRONOUNCED DEAD 11100 Day. YrI
<br />28d. PRONOUNCED DEAD (Hour/
<br />�Y '7
<br />127c
<br />Cf LJ
<br />aaa�
<br />Paula Spotanski
<br />3016 Brentwood Blvd. Grand Island, Nebraska 68801
<br />20 EMBALMER - SIGNATURES I`. /� FN�SE�N�^,. 2ta METHOD OF DISPOSITION 21b DATE 21 CEMETERYCEMETERYORCREMAI.)u1 NAME
<br />� Burial ❑ Removal 2000 Grand Island Cemetery
<br />Dec. 9,
<br />22a. FUNERAL HOME -NAME �— -- _ - - -- - - --
<br />21tl CEMETERY OR CREMAiORVLOC -ON CI TV O1, TOWN STATE
<br />Apfel- Butler - Geddes El Cremation ❑Donalor Grand Island, NE.
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP) —
<br />1123 West Second, Grand Island, Nebraska 68801
<br />23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR gal ibl. AND Ic l) Interval between onset and clan
<br />PART _
<br />1 p'
<br />lal mil.^ '• _ - • - . _ - - . l / � - L... '�_ ,
<br />DUE TO, OR AS A CONSEOUENCE OF Inter >ei helween onset and dealt,
<br />l j
<br />DUE TO. OR AS A CONSEQUENCE OF —
<br />/ / I IP vat be sari onset anc tleaVi
<br />Icl I C,CI -k guy i'JI C I sTC�- V�.' -pl �"� // ��' n -�Q -{--
<br />OTHER SIGN¢ NT CONDITIONS Conditions cinrimbining to the death but not related PART
<br />PART
<br />III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25 WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />j 1I
<br />�( �r,�.lC. �.)'��ir l'�•
<br />IN THE PAST 3 MONTHS'
<br />EXAMINER OR CORONER'
<br />-,'.I- 'L-{ Itr ',=
<br />)Ages 10541 Yes NO L
<br />Yes Na
<br />Yes ❑ No
<br />26. -
<br />266 JATEOFINJ6RY IMO Day. Yr.)
<br />26c HOUR OFINJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />PAccident Undetermined
<br />M
<br />El Suicide F] Pending
<br />26e INJURY AT WORK
<br />261 PACE OF INJURY - At home, farm street. factory
<br />26g. LOCATION STREET OR R.F.0 NO r'.ITY OR TOWN STATE
<br />Homicide Investigation
<br />❑❑
<br />vas
<br />❑
<br />office building, etc ISp
<br />eHomicide
<br />No
<br />27a. DATE OF DEATH /MO. Day. vrl
<br />28. DATE SIGNED (Mo. Day yr
<br />r28b TIME OF DEATH
<br />�!i
<br />i °
<br />= 27b. DATE IGNED 1946 Day Yr,,
<br />TIME OF DEATH
<br />28c PRONOUNCED DEAD 11100 Day. YrI
<br />28d. PRONOUNCED DEAD (Hour/
<br />�Y '7
<br />127c
<br />Cf LJ
<br />aaa�
<br />M
<br />° °
<br />M
<br />° 27d To the best of ni knowledge death occurred at the time, to and place and due to the
<br />28e On the basis of examination and or investigation, in my opinion death occurred at
<br />.
<br />causelsl slated. ) ., r --Y•%)
<br />-i_,�"
<br />_
<br />the time. date and place and due to the cause(51 stated
<br />ISI naure and Title) ► i'i L.. 'r ti3O>4 -.•. ' L�� �-r'
<br />IS, nature and Title) ►
<br />29 DID TOBACCO USE CONTRIBUTE T. T�t JEATHI
<br />30 a HAS ORGAN O TISSUE DONATION BEEN CONSIDERED'
<br />30.1 WAS CONSENT GRANTED'
<br />YES ❑ NO ❑ UNKNOWN
<br />❑ YES 91 NO
<br />❑ YES NO
<br />Jeff Muilenberg M.D. 609 "0" St., Aurora, NE. 68818
<br />32a. REGISTRAR jf. 32b. DATE FILED BY REGISTRAR (Mo. Day n,
<br />DEC 13 200o
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