|
WHEN TM COPY CARRIES TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMA &JERVICES
<br />SYSTEM, IT CERTFIES TIE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORa- ONFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC9rSi T101 , Aiii �fIS__
<br />THE LEGAL DEPOSITORYFOR VITAL RECORD&
<br />DATE OF ISSUANCE -
<br />�1 � AM" &.- COOPER I Sr
<br />0 CT 14 1995 200105178 ASSISINT STATE REGISTI4
<br />LWCOLN, NEBRASKA HEALTH AND HUAMN $EWCEg tEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICESYNANCE AND SUPPORT
<br />VITAL STATISTICS - -
<br />CFRTIFTCATE OF DEATH
<br />1. DECEDENT -NAME- FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Yearl
<br />Vernon Duane Fredericksen
<br />Male
<br />October 2, 1999
<br />4. CITY AND STATE OF BIRTH lent k1 U.S.A.. name country)
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />M
<br />f1
<br />X
<br />`
<br />Omaha, Nebraska
<br />c=.)
<br />►•�
<br />n cn
<br />o -i
<br />o rar7
<br />Be . PLACE OF DEATH
<br />507 -38 -9187
<br />C
<br />f1
<br />v,\
<br />2
<br />Bb. FACILITY -Name (tt not mstduadit give street and number)
<br />C_
<br />=
<br />Tv rr i•
<br />C7
<br />Z
<br />!�
<br />Z
<br />Q
<br />Yep ® No,
<br />Hall
<br />::C1
<br />rn}
<br />91to COUNTY
<br />rn
<br />o CD
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1332 Sherman P1 68803
<br />Yes OX No ❑
<br />. 10. RACE - Iti White. Black. American Indian.
<br />-C O
<br />CD
<br />13. NAME OF SPOUSE fl1 wile. give maiden name)
<br />atc11S11eC11111., rte
<br />112.
<br />(SwdY) American
<br />NEVER DIVORCED
<br />Sue A. Holbert _
<br />14a. USUAL OCCUPATION (Give kind work done dtaklg most 14b.
<br />C
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only no" grade conplelecil
<br />E ry or Secondary 10 -121 Cosege (1 -40,511
<br />4
<br />1'- .,.yn Arekred) -
<br />District Manager of Claims
<br />Farmers Mutual Ins. Co.
<br />t6 FATHER -NAME FIRST MIDDLE UST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Nels Fredericksen
<br />Irene Swanson _
<br />16. WAS DECEASED EVER IN U.S. ARMED FORCES? INFORMANT - NAME
<br />7_1
<br />F_A
<br />13.1,2 Sherman Place Grand Island, Nebraska 68803
<br />EMd MER - SIGNATURE 8 LICENSE N0.
<br />21 a. M:THOD OF DISPOSITION
<br />21b, DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />CZ)
<br />Ir
<br />iiii
<br />13d Burial [] Removal
<br />Westlawn Memorial Pa_ rk
<br />(A
<br />M
<br />�
<br />r
<br />C1l C**
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />1123 West Second Street Grand Island, Nebraska 68801
<br />23. E CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lat. (bl. AND (cl) Interval between onset and death
<br />PART
<br />I I
<br />( I
<br />O
<br />cn '
<br />CAD
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />C
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONE ?
<br />II
<br />(Ages
<br />7c
<br />Yes No
<br />Yes No
<br />26a
<br />26b. DATE OF INJURY (Mo.. Day Yr.J
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident 0 Undetermined
<br />M
<br />n Stkcide ❑ Pending
<br />26e. INJURY AT WORK
<br />We � Y -(W pi. farm, street factory
<br />Speday)
<br />265. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />as
<br />Yes 0 No ❑
<br />1261'
<br />oltic nor
<br />27a. DATE OF DEATH (W... Day. Yr.J
<br />28a. DATE SIGNED (Mo.. Day. Yr)
<br />cn
<br />�
<br />October 2, 1999
<br />M
<br />g
<br />i <
<br />27b. DATE SIGNED (Aila. Day. Yr.)
<br />27c. TIME OF DEATH
<br />o
<br />28d. PRONOUNCED DEAD (Hour)
<br />October ril,l 99
<br />0440 a.m. M
<br />n
<br />6
<br />M
<br />�S.
<br />6
<br />WHEN TM COPY CARRIES TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMA &JERVICES
<br />SYSTEM, IT CERTFIES TIE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORa- ONFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC9rSi T101 , Aiii �fIS__
<br />THE LEGAL DEPOSITORYFOR VITAL RECORD&
<br />DATE OF ISSUANCE -
<br />�1 � AM" &.- COOPER I Sr
<br />0 CT 14 1995 200105178 ASSISINT STATE REGISTI4
<br />LWCOLN, NEBRASKA HEALTH AND HUAMN $EWCEg tEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICESYNANCE AND SUPPORT
<br />VITAL STATISTICS - -
<br />CFRTIFTCATE OF DEATH
<br />1. DECEDENT -NAME- FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Yearl
<br />Vernon Duane Fredericksen
<br />Male
<br />October 2, 1999
<br />4. CITY AND STATE OF BIRTH lent k1 U.S.A.. name country)
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />S. DATE OF BIRTH ~11). Day. Year]
<br />Mos. DAYS
<br />Sc. HOURS MINS.
<br />Omaha, Nebraska
<br />(Yrs.) 66 so.
<br />June 2, 1933
<br />7 SOCIAL SECURTIY NUMBER
<br />Be . PLACE OF DEATH
<br />507 -38 -9187
<br />HOSPITAL: ® Inpatient OTHER: Nursing Hone
<br />1:1 ER Outpatient Residence
<br />Bb. FACILITY -Name (tt not mstduadit give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other(Specrlyl
<br />Be. CITY. TOWN OR LOCATION OF DEATH
<br />.Bd. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island, Nebraska
<br />Yep ® No,
<br />Hall
<br />9s RESIDENCE - STATE
<br />91to COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (hnchMing Zip Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1332 Sherman P1 68803
<br />Yes OX No ❑
<br />. 10. RACE - Iti White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian, Mexican, German, etc)
<br />® MARRIED O WIDOWED
<br />13. NAME OF SPOUSE fl1 wile. give maiden name)
<br />atc11S11eC11111., rte
<br />112.
<br />(SwdY) American
<br />NEVER DIVORCED
<br />Sue A. Holbert _
<br />14a. USUAL OCCUPATION (Give kind work done dtaklg most 14b.
<br />C
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only no" grade conplelecil
<br />E ry or Secondary 10 -121 Cosege (1 -40,511
<br />4
<br />1'- .,.yn Arekred) -
<br />District Manager of Claims
<br />Farmers Mutual Ins. Co.
<br />t6 FATHER -NAME FIRST MIDDLE UST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Nels Fredericksen
<br />Irene Swanson _
<br />16. WAS DECEASED EVER IN U.S. ARMED FORCES? INFORMANT - NAME
<br />�1:,.
<br />(YK, no or unk.) eyes ¢ve war a e•
<br />Yes Kor an War 10/4/55 Sue A. Fredericksen
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />13.1,2 Sherman Place Grand Island, Nebraska 68803
<br />EMd MER - SIGNATURE 8 LICENSE N0.
<br />21 a. M:THOD OF DISPOSITION
<br />21b, DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />1
<br />Ir
<br />iiii
<br />13d Burial [] Removal
<br />Westlawn Memorial Pa_ rk
<br />FLI ERAL H - NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes
<br />El' res' Ell"'
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />1123 West Second Street Grand Island, Nebraska 68801
<br />23. E CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lat. (bl. AND (cl) Interval between onset and death
<br />PART
<br />I I
<br />( I
<br />OM TO, OR AS A CONSEQUENCE OF I Interval between onset and death
<br />I
<br />:bi
<br />DUE TO. OR AS A CONSEQUENCE OF: I Interval between onset and death
<br />I
<br />I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A 24.
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONE ?
<br />II
<br />(Ages
<br />10 -54) Yes No
<br />Yes No
<br />Yes No
<br />26a
<br />26b. DATE OF INJURY (Mo.. Day Yr.J
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident 0 Undetermined
<br />M
<br />n Stkcide ❑ Pending
<br />26e. INJURY AT WORK
<br />We � Y -(W pi. farm, street factory
<br />Speday)
<br />265. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes 0 No ❑
<br />1261'
<br />oltic nor
<br />27a. DATE OF DEATH (W... Day. Yr.J
<br />28a. DATE SIGNED (Mo.. Day. Yr)
<br />28b. TIME OF DEATH
<br />aY
<br />October 2, 1999
<br />M
<br />g
<br />i <
<br />27b. DATE SIGNED (Aila. Day. Yr.)
<br />27c. TIME OF DEATH
<br />23c. PRONOUNCED DEAD (Mo.. Day, Yrl
<br />28d. PRONOUNCED DEAD (Hour)
<br />October ril,l 99
<br />0440 a.m. M
<br />n
<br />6
<br />M
<br />�S.
<br />6
<br />27d. To rib best t% my ath occurred at lime ate and place and due to the
<br />28e. On the basis d examination andlor Investigation, in my opinion death occurred at
<br />cause(sl stated.
<br />v is
<br />the time, date and place and due to the cause(sl stated.
<br />(Signimarre and T
<br />nature and Tide
<br />20. DID TOBACCO
<br />USE CO RIB TE THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.It WAS CONSENT GRANTED?
<br />YES 0 E] UNKNOWN
<br />YES INO
<br />YES NO
<br />31. NAME AND ADDRE E IFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type or Ffiall
<br />Dr. John A. Wagones Jr. 8001AIiiha Grand Island Nebras .6880
<br />=a REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Ma. Day. Yr.)
<br />
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