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<br />STATE OF NEBRASKA
<br />WHEN THIS I' 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 />'6N FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH /S THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />4/7/2017
<br />LINCOLN, NEBRASKA
<br />201900089
<br />Cori
<br />STANLEY S. • OPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Gary Lynn Pedersen OD
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 28, 2017
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Franklin County, Nebraska
<br />(Yrs.)
<br />64
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />October 30, 1952
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />To be completed/verified by: FUNERAL DIRECTOR
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Heslth St. Francis
<br />II ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other(Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c, CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />2333 Stagecoach Road
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />f0a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF, SPOUSE (First, -, Middle, Last, Suffix) If wife, give maiden name
<br />Barbara Frame
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Norris Pedersen
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Joyce Keness
<br />13. EVER IN U.S., ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Barbara Pedersen
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Andrew D. Purcell
<br />16b. LICENSE NO.
<br />1486
<br />16c. DATE (Mo., Day, Yr.)
<br />April 1, 2017
<br />®Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Aofel Funeral Home. 1123 W. 2nd, Grand Island. Nebraska
<br />17b.Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />To be completed by: CERTIFIER
<br />38. PART I. Enter the chain of events --diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />fesp ratory s•re3t, or ventricular fibrillation without showing the etiolc„ no NOT AseoPvIATE Enter nnt, nr. ca,'sc on a line. Add ,don„nal linos 4 nacexsa y.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Heart Failure
<br />disease or condition resulting
<br />onset to death
<br />30 Minutes
<br />in death)onset
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />sequentiany list conditions, if. b) Hypertension
<br />any, leading to the cause listed
<br />line a.
<br />to death
<br />Years
<br />on
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Heart Murmur
<br />Idcsease or injury that Initiated
<br />onset to death
<br />2 Weeks
<br />the events retuning in death) ' DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES '; ®NO
<br />'IIF' FEMALE:
<br />20.l'1
<br />L Not pregnant within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />El Natural ❑ Homicide
<br />Accident Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />0 0
<br />0 Suicide ❑ Could not be determined
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK? -::
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITYROVJN STATE ZIP CODE
<br />-, 23a. DATE OF DEATH (Mo., Day, Yr.)
<br />a 1.14
<br />To be com,,le:ed by
<br />CORONER'S ^H'/SICIAN
<br />or COUNTY ATTORNEY
<br />ONL'
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />31, 2017
<br />24b. TIME OF DEATH
<br />07:01 PM
<br />z :.} 23b. DATE SIGNED (Mo., Day, Yr.)
<br />At E t z
<br />23c. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />Marcie 2::, 2017
<br />24d. TIME PRONOUNCED DEAD
<br />C7:01 PM
<br />3d. To the best of myknowledge, death occurred at the time, date and lace
<br />a � 0 9e,P
<br />- and due to the cause(s) stated. (Signature and Title)
<br />it i
<br />24e. On the basis of examination and/or invesuge.iuc, i^ my ooinion death occurred at
<br />the time, daft and place and due to the cause(s) stated. (Signature e:.6 7,•'e)
<br />Thomas J. Helget, Deputy County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES El NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ❑ NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Thomas J. Helget, Deputy County Attorney, 23
<br />South Locust Street, Grand Island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE /(I /� _
<br />�J
<br />2=b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 5, 2017
<br />
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