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I <br />STATE OF NEBRASKA <br />' <br />4 <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 <br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE <br />10/10/2017 <br />LINCOLN, NEBRASKA <br />CEDENT.AtkAtE - FIRST MIDDLE <br />Colleen. Eleanor <br />4, CITY AND STATE OF BIRTH !d`not : USA. nemm cowaeyl <br />Burs�eli, Nebr <br />8b. FACILITY - Herne >e nm1 atsMUaon. <br />BryanLGH Medical C <br />em CITY TOWN fdA LOCATION OF DEATH <br />SOC W. SECURITY NUMBER <br />• <br />505-12-7308 <br />give strew arc number) <br />East <br />Lincoln <br />ga RESIDENCE- STATE. - 90 COUNTY <br />Nebraska f Hall <br />• 10.RACE- (*gOalbe Bl ack American In0an. <br />ee 1160,5lyi White`: <br />15. FATHER -NAME <br />1E <WA DEGEA$ED EVER uN <br />` a � :aYes. 9' <br />14a USUAL OCCUPATION /Give kwIcar I0(6 dO r, 21004 maa <br />d Acdoex0 eye. town araara01 <br />FIRST <br />Teacher <br />Charles <br />.S. <br />. AWED FORCES? <br />Wes nn 1ai7g:1 <br />W war and came ol services) • No <br />lab .NFORMANT MAILING ADDRESS <br />900 S outh 56th St., <br />20: EMS ALMR,R - SIGNATURE *:LICENSE NO <br />22a FU RAU $OME - N <br />Li'rlingston- Sondermann Funeral Hc[ar-mmat^ DPra <br />FUNE RAI>MANE At D RESS: (STREET OR RF.D. NO.. CITY OR TOWN. STATE 21P1 <br />01 N« Webb Grand Island, Nebraska 68803 -4050 <br />(el <br />101 <br />MEDIATE CAUSE <br />DUE - I. OR AS <br />0 Ace0ent � Undetermmeo <br />Ell Swctde 0 Ponpgng , 26e INJURY AT WORK <br />lin HOmIf11011 : 9Neylg0900n. Yes [] No r i 00 <br />a <br />STATE OF NEBRASKA- DEPARTMEENf OF HEALTH AND HUMAN SERVICES FINANCE ARID SUPPORT <br />VITAL STATISTICS 03 .09992 <br />CERTIFICATE OP DEATH <br />11. ANCESTRY leg.. 000.0. Macon. German. atet <br />I$0ecO44 American <br />MIDDLE LAST <br />Meyer <br />!STREET OR R.F.D NO: CRY' OR TOWN. STATE. 21P1 <br />Lincoln Nebraska 68516 <br />OTHEA.SIGNIFICANT CONDITIONS • .:ondecros conetu5gg I0 the death but not regaled. <br />26b DATE OFINJURY /Ab Day. Yr) <br />20170814 <br />LAST <br />Larsen <br />56. AGE - Last 13144Iy 1 UNDER 1 YEAR <br />(Yr� 1 SD MOS ! ' DAYS <br />ea PLACE OF DEATH <br />HOSPITAL <br />84 INSIDE CRY UMITS <br />Ye8 No fl <br />9c. CITY. TOWN OR Local <br />Grand Island <br />I NEVER <br />145 1010 OF BUSINESSJNDUSTRY <br />Public Schools <br />218.6461600 OF DISPOSITION <br />&mai 0 Remov <br />17 MOTHER <br />. /ENT ONLY ONE PER LINE FOR .oI tbl, AND ICI) <br />u� c�C'I ae <br />E Tp OR AS ONSEOUENCE OF <br />.\ - e44 w2 Q_CX cQ © ace <br />ENC£ OF <br />M <br />261 Waco b o/dIng e840 %Spy 7 warm 5agM1 tet70ry <br />26g LOCATION <br />2 5E.4 £' . <br />Female <br />UNDER 1 DAY <br />Sc. MINS <br />u ER OLepaeere <br />0 . - <br />DOA <br />12. .1 ,i MARRIED Q WIDOWED <br />1-'F DIVORCED <br />FIRST <br />Byrdie <br />198. INFORMANT - NAME <br />Jeannie Bergholz <br />PART (81F FEMALE WAS THEREA I2a AUTOPSY • <br />1 <br />PREGNANCY IN THE PAST' "ONTHS'a <br />(Ages 10.541 YnYr., D Vb ❑ l - Yes N <br />260 HOUR OF INJURY 12&tDESC'.g8E HOW iN /50(1 OCCURRED <br />3 <br />SERVICES, VITAL <br />1 <br />STANLE. COOPER <br />ASSIST T STATE REGISTRAR <br />DEPARTMENT HEALTH AND <br />HUMAN SERVICES <br />DATE OF DEATH A14ra b Day Very <br />September 2, 2003 <br />& DATE OF BW Nola ms a Dry 4. <br />October.10, 1921 <br />OTHER. Nw509 Horne <br />❑ Rrr 610(0 <br />Oter?Spec*. _... <br />66 COUNTY OF DEATH <br />Lancaster <br />94 STREET AND NUMBER Mao/49Z° Cadet 9e IN 5+0E � ..., <br />1904 W. 16th St. 68803 1 <br />13. NAME OF SPOUSE toase.omedlrdmRM* <br />'1 <br />Vaughn Larsen <br />pe <br />15. EDUCATION (Sedy only what grade compMece <br />m <br />Eleentary ce Secondary .0-121 <br />MIDDLE . MAIOEN SURNAME <br />Wicks <br />216 1E 210 CEMETERY OR CREMATORY NAME <br />Sept. 5, 2003 Grand Island City Cemetery CIT <br />21d CEMETERY OR CREMATORY LOCATION Y OR TOWN . STATE <br />Grand Island, Nebraska <br />STREET OR R F.D. NO CITY OR 101 <br />/mama] between onset 4 0605 <br />6901,105648861' onsesa041 dean <br />MeemI awe awaear <br />25. WAS , :9SE REF 5 (70 MoC, (C. AL <br />Ey.AMINER OR CORONER? <br />Yes n <br />270 A:ATEOF OWN /Aso Day Yr) <br />I SIGNED } 274 Y r ! <br />( 274I T°1 *Si d my 4fa0wl / o + 0m m and p la c e and • .9 ° v 28e On Me baslsof:examinabon and or n esagabon.. my 00eapn ream acronym ..I <br />2 {,8 0 gIN :' / ✓ - ...3 - the (11ne Oa* and place and 000 b the canals slated. <br />I re and li Il 1Sgnanae and TEe) fa <br />29 DID TOBACCO USE C. - : : • • T.� • • EAT . 30.a HAS ORGAN OR T SUE DONATION SEEN CONSIDERED? • 30 b WAS CONSENT GRANTED' <br />i YES ►4 NO . / UNKNOWN ES 0 NO YES <br />1 31 NAME ANO ADDRESS CERT10IER:PHYSICIAN. CORONER 5 PHYSICIAN OR COUNTY A NEVI Y '70303, Pnn <br />EG L 1 <br />296 PRONOUNCED DEAD ?Ma D4Y. Yr! 254. PRONOUNCED DEAD. 1'lo1r <br />• <br />A ) 1 /) 1 329 DATE FILED BY REGISTRAR (Ala Day '1 / <br />I ,,�' � . ' -} : iJ° SEP 0 8 2003 <br />W <br />0 ' D <br />W <br />