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20010'7140 <br />WHEN THIS COPY CARRFES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN -MRVICES <br />SYSTEM, R CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOB0 ON FILE WITH <br />THE - NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS CVON,-VON _ <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS = <br />DATE OF ISSUANCE <br />g t_4jANLkY23,CQ0_AER_ <br />JUN 1 V Z ASSISTA WTBTATE REGISTRAR <br />LINCOLN, NEBRA� HEALTH AND HUMAhi SERVICES SYSTEM -: <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVIC9S FINANCE ANDSUPTURT <br />VITAL STATISTICS _ - n <br />CERTIFICATE OF DEATH J �. <br />I DECEDENT - NAME FIRST MIDDLE LAST <br />I ' SE% <br />3 DATE OF DEATH M 11 Oar Yearl <br />Wilma E• Christensen <br />Female <br />January 5,2001 <br />4. CITY AND STATE OF BIRTH Afoot in USA country/ <br />Sa AGE - Last Birthday <br />UNDER I YEAR <br />UNDER t DAY <br />6. DATE OF BIRTH (Month. Dav Year) <br />Kearney County, Nebraska <br />Y's 5b <br />78 <br />MOS. DAYS <br />5c HOURS MINS <br />June 24, 1922 <br />7. SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH -- -- -_- - <br />508 -14- 9430 <br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home <br />❑ ER Outpatient Residence <br />8b. FACILITY -Name if not institution, <br />/ give street and number) <br />1919 N. Park Ave. <br />❑ DOA ❑ Other <br />8C. CITY. TOWN OR LOCATION OF DEATH <br />8d. INSIDE CITY LIMITS <br />Be COUNTY OF DEATH - <br />Grand Island <br />yes FX] No ❑ <br />Hall <br />9a. RESIDENCE - STATE <br />9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d STREET AND NUMBER ltnc,udrbg Zip Code, <br />9e INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />1919 N. Park Ave. 68803 <br />Yes ® Np ❑ <br />10. RACE - (e. g., White. Black. American Indian, <br />11. ANCESTRY Ie g. Italian Mexican, German, etc1 <br />12. Qq MARRIED ❑ WIDOWED <br />L <br />13 NAME OF SPOUSE if wde give maiden name) <br />etc.) ISneciryl <br />White <br />(specify) <br />German <br />NEVER <br />MARRI DIVORCED <br />Clyde Christensen <br />14a USUAL OCCUPATION /Give kind of work done during most <br />tdb KIND OF BUSINESS INDUSTRY <br />15 EDUCATION (Specify only n�ghest grade completed) <br />of working /de, even it retired, <br />- 6-Beautician <br />Hair Styling <br />Elementary or Secondary 10 121 College i I .4 or S <br />1 Yea r <br />16. FATHER -NAME FIRST MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME <br />]17 <br />Chris Petersen Carrie Jacobsen <br />18 WAS DECEASED <br />EVER IN US. ARMED FORCES? <br />19a INFORMANT - NAME <br />(Yes no or unkl <br />If yes give war and dates of services) <br />No I <br />-- - - - - -- <br />Cl de Christensen <br />19b INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO_ CITY OR TOWN. STATE. ZIP) <br />1919 N. Park, Grand Island, Nebraska 68803 <br />20. EM LM ER - SIGN RE 8 LCENSE NO <br />n � <br />21 a. METHOD OF DISPOSITION <br />21b. DATE T21d CEMETERY OR CREMATORY NAME <br />� / <br />Burial ❑Removal <br />Jan. 8, 2001 Minden Cemetery <br />22a. F NERAL HO -NAME <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Layton Funeral Home <br />❑ Cremation ❑ Donatmn <br />Minden, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP) <br />336 N. Nebraska, Minden, Nebraska 68959 <br />23 ART IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a). (bl. AND (0 Interval between onset and dealn <br />y <br />(a) Cardiac arrest <br />DUE T0, OR AS A CONSEQUENCE OF Interval between onset and deam <br />(b) <br />DUE TO. OR AS A CONSEQUENCE OF Inte—i between onset and deal, <br />(c) <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />PART <br />111 IF FEMALE. WAS THERE A 24 <br />AUTOPSY <br />25 WAS CASE REFERRED TO MEDICAL <br />PREGNANCY <br />IN THE PAST 3 MONTHS' <br />�- <br />EXAMINER OR CORONER' <br />(Ages <br />10-54) Yes No <br />Yes No <br />yes No <br />26a <br />26b DATE OF INJURY (Mo. Day. vr.) 26c HOUR OF INJURY <br />_. <br />26d. DESCRIBE HOW INJURY OCCURRED <br />Accident ❑ Undeten —ed <br />M <br />F1 Suicide ❑ Pending <br />26e INJURY AT WORK <br />26f PLACE OF INJURY - AI home. farm street. factory <br />21 LOCATION STREET OR R. F, D. NO -ITY OR TOWN STAT= <br />Homicide Investigation <br />❑❑ <br />yes No <br />❑ <br />office budding. etc (Specify) <br />27a. DATE OF DEATH IMO Yr.) <br />28a DATE SIGNED lMo. Dav Yr I <br />28b TIME OF DEATH <br />4- approx <br />w <br />M <br />_ `r' <br />27b. DATE SIGNED (MO.. Day. W.) <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD (Mo. Day. Yc) <br />28d PRONOUNCED DEAD (Noun <br />FO <br />v ¢ <br />F <br />M <br />M <br />a <br />o <br />27tl. To the best of my knowledge. death occurred at the time. date and place and due to the <br />28e On the basis o examination and or investigation, in my op�,nipn tlealn occurred at <br />causels) stated. <br />)/(fie time, date and place and due to the causee(sl staled. <br />(Signature and TiNe) ► <br />(Si nature and Title ) ► -"f U,-, <br />29 DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b <br />WAS CONSENT GRANTED'r <br />� <br />❑ YES ❑ NO [ L UNKNOWN <br />�j <br />X ❑ YES I VI NO � <br />i <br />❑ YES NO <br />31 NAM' AND ADDRESS OF CERTIFIER, fPHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY /Type or Prim) <br />t t D Vitera GIPD 131 S Locust, Grand NE 68801 <br />32a REGISTRAR <br />32b DATE FILED BY REGISTRAR (Mo. Day yr I <br />AN 16 2001 <br />