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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORDLON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIMISIECTIQ fi WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE SEP 1 3 2005 LINCOLN, NEBRASKA STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANOEAND SUPPORT 099 Last, 2. SEX 3. DATEOPDE/4TI' (Mo., Day, Yr.) Larsen Male September 2, 2005 1. DECEDENT'S -NAME (First, Vaughn 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Marquette, Nebraska 7. SOCIAL SECURITY NUMBER 507 -42 -2550 8b. FACILITY -NAME (If not Institution, give street and number) Wedgewood Care Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island,' NE. 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 1904 West 16th 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Harold 13. EVER IN W U.S. ARMED FORCES? Give dates of service if yes. 14a. INFORMANT -NAME (y 0 4405:454h.)14. II 12/18/44 - 11/18/ 6 Jean Bergholz 15. METHOD OF DISPOSITION XI Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston - Sondermann F.H. 601 N. Webb Rd. Grand Island, NE. 18. PART I. Enter the chain of eve nts -- diseases, injuries, or complications- -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE (Final disease or condition resulting In death) Sequentially 8st conditions, if any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or injury that Initiated the events resulting In death) LAST 22d. INJURY AT WORK? ❑ YES ❑ NO 28a. REGISTRAR'S SIGNATURE IMMEDIATE CAUSE: DUE TO, OR AS A CONSEQUENCE OF: (a) (b) DUE TO, OR AS A CONSEQUENCE OF: (c) (d) Middle, 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. 23a. DATE OF DEATH (Mo., Day, Yr.) X September 2, 2005 Middle, Eugene 9b. COUNTY 16a/$M BALMER- SIGNATU R � GGe� t�Q- t'k DUE TO, OR AS A CONSEQUENCE OF: 22e. DESCRIBE HOW INJURY OCCURRED 201706706 CERTIFICATE OF DEATH Hall Last, Larsen 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery 18. PART II. OTHER SIGNIFICANT CONDITIONS Condltlons contributing to the death but not resulting in the underlying cause given in PART I. 21a. MANNER OF DEATH �lrJ atural ❑ Homicide m 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife give maiden name. ❑ Accident❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify) CITY/TOWN 23b. DATE SIGNED (Mo. Day, Yr.) 23c. TIME OF DEATH X � , 5 N 7:15 pm 23d. To th b st of m wledge, death occur ed at the time, date and place and due to the c @(s) slat Sign re and Title ) • r Ir , 5a. AGE -Last Birthday (Yrs.) 79 25. DID TOBACCO US6ONTRIBUT g1 0 THE DEATH? // R YES ❑ NO ❑ PROBABLY ❑ UNKNOWN X O YES Suffix) 8a. PLACE OF DEATH HOSPITAL: eT TAhrErS. ASSISTANT STATE REGtST HEALTH AND HUMAN **WIVES' 5b. UNDER 1 YEAR MOS 9c. CITY OR TOWN DAYS ❑ Inpatient ❑ ER /Outpatient IS?4 ❑ Colleen Schulling Suffix) 12. MOTHER'S -NAME (First, Ida 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? . NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUFIT��RNEY) (Type or Print) 5c. UNDER 1 DAY HOURS 16b. LICENSE NO. th CITY / TOWN Grand Island 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 240. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) Sr. Gordon J. Hrnicek, M.D., 729 N. Custer, Grand Island, MINS. 4IHE8: ai Nursing Home /LTC ❑ Hospice Facility ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall Grand Island 9e. APT. NO 9f. ZIP CODE 68803 Middle, NE B _DATE OF BIRTH (Mo., Day, Yr.) July 4, 1926 9g. INSIDE CITY LIMITS l YES ❑ NO Maiden Surname) Danhauer 14b. RELATIONSHIP TO DECEDENT Step- daughter 16c. DATE (Mo., Day, Yr. ) September 7, 2005 STATE 24b.TIME OF DEATH 68803 SEP = 8 2005 Nebraska 17b. Zip Code 68803 APPROXIMATE INTERVAL pnset to de th onset to death onset to death onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? x ❑ YES )40 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? X ❑ YES ❑ NO ZIP CODE m 24d. TIME PRONOUNCED DEAD m 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date end place and due to the cause(s) stated. (Signature and Title) • 26b. WAS CONSENT GRANTED? X "Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)