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200103511 WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALT1+AND h MAN_ _SERVICES SYSTEM, lT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIG0 -REC RGONAXE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAiIST/GS SECTKSK,W1'HCH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE - DEC 18 2000 200104336 -: ANtlY CODER ASSISTANT STATE RE613tAR LINCOLN, NEBRASKA HEALTH ARD HUMAN SERmES STEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN S9P VICES ftNANCE, RD SUPPORT VITAL STATISTICS _ _ _ CERTIFICATE OF DEATH' =- _ t DECEDENT -NAME FIRST MIDDLE LAST 2 SEX �3 DA TE OF DEATH ,M��ntr, (�,jt Years Ivan Homer Paulson Male December 4, 2000 4. CITY AND STATE OF BIRTH Innotin USA namecounfryl 15a AGE Last Birthday UNDER YEAR UNDER DAY 6 DATE OF BIRTH ,Mont. Da> rear Hastings, Nebraska IyrsI 90 Sb MOS DAYS 5c HOURS MINIS i October 5, 1910 7 - -- - - -- _..... 7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH - 506 -05 -1310 HOSPITAL ❑ Inpatient OTHER ® Nurvng Home 810 FACILITY - Name III not mstiluhon, givesfreel and number/ ❑ ER Outpatient ❑ Residence Hamilton Manor ❑ DOA ❑ Othe„Sr-1, 8c CITY TOWN OR LOCATION OF DEATH Ad INSIDE CITY LIMITS Be COUNTY OF DEATH - Aurora ( Yes r�K No F— Hamilton 9a RESIDENCE - STATE 9b COUNTY 24 AUTOPSY 9c CITY. TOWN OR LOCATION PREGNANCY �.1 l'- � ��. 9d. STREET AND NUMBER Jnrruddng Zip Code) 1 9e INSIDE CITY LIMITS Nebraska Hall t (E- " Grand Island Yes No 3008 Orleans Drive [A 126a - 26b JATEOFINJ6RY /MO Day Yr.) 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED F] Accident r-1 Undetermined Yes No ❑ 10 RACE - (e.g.. White. Black. American Indian 11 ANCESTRY leg Italian. Mexican. German, etcl 12 ❑MARRIED © WIDOWED 13 NAME OF SPOUSE .l1 wile give maiden name) etc llSoechl to ISDeotyl 1 tills American 26g. LOCATION STREET OR F.F.D. NO 17 TY OR TOWN STATE NEVER DIVORCED MARRI Marjorie Ernst 14a USUAL OCCUPATION rGrve kind of work done during most ab KIND OF BUSINESS INDUSTRY plant 15 EDUCATION �Specily only highest gratle cpmpleted) pec,ty olworkr rile, even ArarGdl Eire C�Iief [Cornhusker Army Ammuniti0 ElementarIO S 10121 College t4ni h -I �i 16 FATHER -NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Claude Paulson y i Mary Dunker 18 WAS DECEASED EVER IN US. ARMED FORCES? 19a WFORMANT M¢ Ye%or unk.) I (It yes give war and dares of serviced i 27d To the best of knowledge death pccurred al the lime date and olaoe and due Io the _ 28e On the basis of e.ammaaon and or invesligatlon. in my opinion death occurred at 2 Paula Spotanski 20. EMBALMER - SIGNATUREB NSEN 21a METHOD OF DISPOSITION 121b DATE 21c C -c METERYC -c METERV OR CREMAIJv� NAME JK`e [xi Burial ❑Removal Dec. 9, 2000 Grand Island Cemetery 22a. FUNERAL HOME NAME 210 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel- Butler - Geddes ❑Cremation ❑Donatior Grand Island, NE. 22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP) 1123 West Second, Grand Island, Nebraska 68801 23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR :al bit AND Ic)I Interval between onset and J-11, PART I DUE TO OR AS A CONSEQUENCE OF Inter,ai oetween onset ano dealt, DUE TO, OR AS A CONSEQUENCE OF V , Ito vat between ousel and deam OTHER SIGN¢ NT CONDITIONS � Conditions contributing to the death but not related PART PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL PREGNANCY �.1 l'- � ��. IN THE PAST 3 MONTHS, EXAMINER OR CORONER, t (E- " (Ages 10 -54) Yes 0 No Yes No Yes ❑ No 126a - 26b JATEOFINJ6RY /MO Day Yr.) 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED F] Accident r-1 Undetermined M 0 Suicide ❑ Pending 26e INJURY AT WORK 261 PLACE OF INJURY - At home. farm. street. tactory 26g. LOCATION STREET OR F.F.D. NO 17 TY OR TOWN STATE Homicide Investigation Yes[] ❑ ❑ office building. etc (Space I 27a. DATE OF DEATH /MO. Day Yr) 28a DATE SIGNED (Min Day vr; r28b TIME OF DEATH M y i 27p. DATE IGN (lo.. Day vr) 27c TIME OF DEATH 28c PRONOUNCED DEAD !Mo Day. Yrl 28tl. PRONOUNCED DEAD (Hour/ //ED-- M¢ z° M o 0 0 27d To the best of knowledge death pccurred al the lime date and olaoe and due Io the _ 28e On the basis of e.ammaaon and or invesligatlon. in my opinion death occurred at 2 cause(sl stated. I .._ -V, I ° = the time date and place and due to the causes) stated Si nature and Title) '� U f ��'.`K -L" � f nature and Title) 29 DID TOBACCO USE CONTRIBUTE T T�t JEATHI 30.a HAS ORGAN O TISSUE DONATION BEEN CONSIDERED, 30.b WAS CONSENT GRANTED, YES ❑ NO ❑ UNKNOWN ❑ YES [XNO ❑ YES NG I -. ___._...._.......—... --- .....-.. r1 1 1,r.-. -.1. ,v..v o-mo11 --I- -i r ni I--1 II yuew rnnrl Jeff Muilenberg M.D. 609 "Off St., Aurora, NE. 68818 32a REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo.. Day n.) DEC 13 2000