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1. DECEDENTS -NAME (First, Middle, Last, Suffix) <br />Ronald Eugene Matheson <br />4. CITYAN <br />D STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH <br />Laramie, Wyoming <br />7. SOCIAL SECURITY NUMBER <br />520 -48 -7531 <br />8b. FACILITY -NAME (If not Institution, give street and number) <br />518 Cottonwood Street <br />5a. AGE - Last Birthday <br />(Yrs.) <br />73 <br />9b. COUNTY <br />Howard <br />5b. UNDER 1 YEAR <br />MOS. <br />DAYS <br />2. SEX <br />Male <br />5c. UNDER 1 DAY <br />HOURS <br />MINS. <br />❑ DOA ❑ Other (S <br />9c. CITY OR TOWN <br />St. Libory <br />8d. COUNTY OF DEATH <br />Howard <br />IX <br />b <br />w <br />DC 8c. CITY OR TOWN OF DEATH (Include Zip Code) <br />St. Libory 68872 <br />cc 9a. RESIDENCE -STATE <br />z Nebraska <br />7. 9d. STREET AND NUMBER <br />j, ' 515 Cvtt.Or.�rc3id J....c t <br />a <br />N <br />= <br />Si <br />IL) <br />4 <br />0. <br />10a. MARITAL STATUS AT TIME OF DEATH El Married ❑ Never Married <br />❑ Married, but separated; ❑ Widowed ❑ Divorced ❑ Unknown <br />11. FATHER'S -NAME (First, Middle, Last, Suffix) <br />Roy Matheson <br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. <br />(Yes, No, or Unk.) Yes 01/24/1968-01/12/1970 <br />15. METHOD OF DISPOSITION <br />❑ Burial ❑ Donation <br />® Cremation ❑ Entombment <br />❑ Removal © Othec:(Specify) <br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) <br />Peters Funeral Home. 302 Second Street. PO Box 181. St. Paul. Nebraska <br />CAUSE OF DEATH (See instructions and examples) <br />18. PART I. Enter the chain of eJei is -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, <br />re$ piratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. <br />IMMEDIATE CAUSE: <br />IMMEDIATE CAUSE (Final a) Sudden Cardiac Death <br />disease or condition resulting <br />in death) <br />Sequentially list conditions, if <br />any, leading to the Cause listed <br />on lines. <br />Enter the UNDERLYING CAUSE <br />(disease or injury that initiated <br />the events resullmgan death) <br />LAST <br />LL 20. IF FEMALE: <br />❑ Not pregnant within past year <br />UJ ❑ Pregnant at time of death <br />rt <br />16a. EMBALMER - SIGNATURE <br />Not Embalmed <br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN <br />Central Nebraska Cremation Services <br />DUE TO, OR AS A CONSEQUENCE OF: <br />b)Coronary Artery Disease <br />DUE TO, OR AS A CONSEQUENCE OF: <br />c) Hypertension <br />DUE TO, OR AS A CONSEQUENCE OF: <br />d) <br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden n <br />Sharon L Kleinschmidt <br />12. MOTHER'S -NAME (First, Middle, Maiden Surname) <br />Evelyn Wilkins <br />14a. INFORMANT- NAME <br />Sharon L Matheson <br />Gibbon <br />21a. MANNER OF DEATH <br />® Natural ❑ Homicide <br />❑ Accident ❑ Pending Investigation <br />16b. LICENSE NO. <br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. <br />21b, IF TRANSPORTATION INJURY <br />❑ Driver /Operator <br />❑ Passenger <br />onse <br />Min <br />1 <br />WHEN ! THIS !''COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT <br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD <br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL <br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE <br />1/4/2017 <br />LINCOLN, NEBRASKA <br />❑ Nat pregnant, but pregnant within 42 days of death <br />T Not nregnattt, NA pregnant. 43 days to 1 year before death <br />❑ Unknown if pregnant Within the past year <br />22a. DATE OF INJURY (Mo., Day, Yr.) <br />22b. TIME OF INJURY <br />22e. DESCRIBE HOW INJURY OCCURRED <br />22d. INJURY AT WORK7 <br />YES ❑ NO <br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. <br />S ATE SIGNED (Mo., Day, Yr.) <br />• <br />23c. TIME OF DEATH <br />3d. To the best of my knowledge, death occurred at the time, date and place <br />and due to the cause(s) stated. (Signature and Title) <br />28a REGISTRAR'S SIGNATURE <br />201702625 <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES <br />CERTIFICATE OF DEATH <br />❑ Suicide ❑ Could not be determined <br />CITY/TOWN <br />8a. PLACE OF DEATH <br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC <br />0 ER/Qutpatient ® Decedent's Home <br />fl* <br />* <br />. APT. NO. <br />❑ Pedestrian <br />0 Other )Specify) <br />STANLEY S. COOPER <br />ASSISTANT STATE REGISTRAR <br />DEPARTMENT HEALTH AND <br />HUMAN SERVICES <br />9f. ZIP CODE <br />6 5872 <br />STATE <br />3. DATE OF DEATH (Mo., Day, Yr.) <br />December 28, 2016 <br />6. DATE OF BIRTH (Mo., Day, Yr.) <br />October 11 1!' <br />pecify) <br />onset <br />ame <br />24a. DATE SIGNED (Mo., Day, Yr.) <br />December 29, 2016 <br />2 4c. PRUNUUivf,ED GEMO (Mo., Day, Yr.). Z4d. TfME PRONOLi . . <br />December 28, 2016 05:46 PM <br />u C <br />8 z 'o <br />12 2 <br />o David T. Schroeder, Howard County Attorney <br />❑ Hospice Facility <br />28b. DATE FILED BY REGISTRAR (MO. <br />December 29, 2016 <br />9g. INSIDE CITY LIMITS <br />I w VES ❑ NO <br />14b. RELATIONSHIP TO DECEDENT <br />Spouse <br />16c. DATE (Mo, Day, Yr.) <br />December 29, 2016 <br />STATE <br />Nebraska <br />17b. Zip code <br />68873 <br />APPROXIMATE:INTERVAL. <br />to death <br />utes <br />onset to death <br />onset to death <br />19. WAS MEDICAL EXAMINER <br />OR CORONER CONTACTED? <br />El YES 0 NO <br />21c. WAS AN AUTOPSY PERFORMED? <br />❑ YES NO <br />21d. WERE AUTOPSY FINDINGS AVAILABL <br />TO COMPLETE CAUSE OF DEATH ? :, <br />LJ ONr <br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) <br />24b. TIME OF DEATH <br />Approx. O5:25 PM <br />24e. On the basis of examination and /or investigation, in my opinion death occurred at <br />the time, date and place and due to the cause(s) stated. (Signature and Title) <br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN €OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? <br />El YES ❑ NO ❑ PROBABLY ® UNKNOWN ❑ YES 1E NO Not Applicable if 26a is NO ❑ YES <br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print <br />David T. Schroeder, Howard County Attorney, 612 Indian St., Ste 3, St. Paul, Nebraska, 68873 <br />"ZIP; CODE <br />