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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALS! ANQ'HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BEA TRUE COPY OF THE ORIGIN , NECONIIQN.OLgWITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL $'i A != 7JOO/, t H IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />JUN 1 9 2007
<br />LINCOLN, NEBRASKA
<br />201906668
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE
<br />VITAL STATISM
<br />S
<br />CERTIFICATE OF DEATH
<br />I 1 DECEDENT - NAME FIRST MIDDLE LAST
<br />Harley Dean Rozendal
<br />2 SEX
<br />Male
<br />UNDER' DAY
<br />A, DA OF DEATH 'N696* DAF Yarn
<br />x I
<br />No'deotber 09,1004,;',
<br />6 BAST OF BWTH Abate Dart
<br />4 CITY AND STATE OF BIRTH .CANe' U Se naNa Colmer
<br />SA AGE• Last B4N0$A
<br />UNDER, YEAR
<br />West Point, Nebraska
<br />IYn,
<br />55
<br />56 MOS ' DAYS
<br />59 HOURS MINS
<br />1Vray.08, 1949'
<br />7 SCKCALSECURTIY NNUMSEP
<br />505-68-0908
<br />Ba P ACE OF DEATH
<br />HOSPITAL C� Mammal OTHER
<br />III
<br />ng tom.
<br />..,14.5.
<br />❑ ER Ouremerd 0 Raibence
<br />99 FACILITY - Name II rot ',,5011140.. gr 00.6.4! ae' M..m0141
<br />St. Francis Medical Center
<br />❑ DOA ❑ Owe, ,SPe- 4
<br />COY TOWN OR LOCATION OF DEATH '60 INSIDE CITY LIMITS
<br />C,rand Island - • - ' Yes El No ❑
<br />i
<br />6e COUNTY OF DEATH
<br />Hall _ .
<br />*Tf
<br />911 RESIDENCE - STATE 196 COUNTY ScICITY TOWN OR LOCATION 90 STREET AND NUMBER •rce.0e'9Zc Cow 9e IN.IDE CRY UMMTS
<br />Hail Grand Island $22 E. Bismark Ave., 68801 v4] No 0
<br />q Slav AmNCan rMan '11 ANCESTRY -eg Wier Memen Geo. MCI 12 '1 MARRIED D WIDOWED -13 NAME OF SPOUSE • 0,.. ice,...mi
<br />�f�c • �Y �-J w t asteel
<br />VYslte N. DntcO' 1 NEVER
<br />MARR6E0 ❑ EMVORCED Florence E. !tsdal
<br />Ida JSUAI OCCUPATION G. made, my* MeN Wong most I tab KIND OF BUSINESS INDUSTRY J15 EDUCATION ISOSCA, e'y woo oaw..-waso
<br />.o.IM MR ar„n memo
<br />(Automotive
<br />Nebraska
<br />tO �.. __ le WIMe
<br />Auto Technician)
<br />Eleemeisce a Seeenco . 4 ¶21 CoM6e • a v 5 -
<br />FATHER • NAME FATHER -NAME
<br />R.
<br />FIRST
<br />MIDDLE
<br />Vernon
<br />LAST
<br />Rozendal
<br />17 MOTHER FIRST MIDDLE WIDER SURNAME
<br />Irene (NMI) Liibbe
<br />18 WAS DECEASED EVER NUS ARMED FORCES' 06/27/1969— 119e INFORMANT • NAME
<br />Yes ro a Int 1 I resnM .ran nM 0a1er el tanaaIal
<br />YesViet Nam War 06/26/1975 1 Florence E. Rozendal
<br />MAILING ADDRESS ,STREET ORR F NO . CITY OR TOWN STATE ZIP,
<br />196 INFORMANT
<br />1822 E Bismark Ave., Grand Island, Nebraska 68801
<br />EMBALMER • SIGNATURE I LICE
<br />22a FUNERAL
<br />Kleine Fer1 Home
<br />1254
<br />21a METHOD OF DISPOSITION
<br />❑ Banal 0 Removal
<br />faCommon ❑ D4aTir
<br />216 DATE
<br />11/13/2004
<br />21c CEMETERY OF, CREMATOPY NAME
<br />Central Nebraska Cremation Service
<br />210 CEMETERY OR CREMATORY LOCATION
<br />Gibbon, Nebraska
<br />CITY ;,F TOWN STATE
<br />226 FUNERAL HOME ADDRESS
<br />(STREET OR R.F D NO CITY OR TOWN STATE. ZIP)
<br />3213 W North Front St Grand Island, NE, 68803
<br />23 IMMEDIATE CAUSE CENTER ONLY ONE CAUSE PER LINE FOR ,ar DI. AND ILII
<br />PART
<br />I L /
<br />a, CJ lO.YLf�j�,e.I� 9�Ci1/Mal
<br />Mimi meow cowl NW 04414
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />is, ACrl y 01.1/0-4/.4;.4 Ada.40.44';..e...
<br />6I L44,
<br />DUE TO OR AS A CONSEQUENCE OF
<br />001.5 _Gil .c6r4,4
<br />M*..al 061• 41140 MMQ sec DNI
<br />He, a, teener, anent r1C Gear
<br />PART OTHER SIGNIFICANT CONDITIONS - Con4Mons Ca SIWII9 b IM owe de AM remise
<br />PART II IF FEMALE WAS THERE A ' 24 AUTOPSY
<br />PREGNANCY IN THE PAST 3 MONTHS',
<br />1 Ages 13.54) Yes n No ❑ I Yes
<br />26a 1266 DATE OF INJURY 1661 DAr v. I 26c HOUR OF INJURY ' 260 DESCRIBE HOW INe1RY OCCURRED
<br />r
<br />ACcpnt D U•IOele"ssed
<br />'
<br />I ,u 5..0.0 Pergmg i 266 INJURY AT WORK
<br />'� •b's[b! Invest•galbn I yes 0 NG 0
<br />� 1
<br />27a DATE OF DEATH IAN Dar v,l
<br />/// 9/e y
<br />3 276 DATE SIGNED .Me Day v., 27c TUE OF DEATH ,} C Zee PRONOUNCED DEAD AN Ab. F' I 12a0 PRONOUNCE', DEAD .«..
<br />6 2 I M i 6
<br />AAASAA 2%0 T: me Dell 01 my • norMOae Neil OCC✓.e0 al IM sine 0016 and ohne, Era Our to we 266 On Ile 5144 a Nauss* on Ano 0, n
<br />Cause's, stable !Y _ ^»11i9r� nM plow" wrn xc.r�1 at
<br />C! aA /r t•m6 4M ane dace aro Our 10 M MONS. MOO
<br />I.
<br />. D • ,
<br />,Sgoare end Tres /��LI '/i,[ \\ �SaMaae anetrN►
<br />I ?9 OCU TOBACCO USE CONI JW DEATH, f, Jo. HAS ORGAN OP TISSUED NASI N BEEN COMSIDEFED� 305 WAS CONSENT GRANTED,
<br />I❑ .ES NO ❑ UNKNOWN ❑ YES X W'1 I ❑ YES at NC
<br />1 31
<br />I
<br />M
<br />25 WAS CASE REFERRED TO MEOiL
<br />EA/OWNER OR CORDNEer
<br />yes El
<br />7Z
<br />261 PLAeCE QF tNJTJRY - AF N7, )arm .n ..
<br />1a0bW
<br />269 LOCATION STREET OR R FD NO C"¶OFI TOWN STATE
<br />264 DATE SIGNED ISA, Day v - 1200 TUE OF DEATH
<br />•
<br />NAME AND ADORESS OF CERTIFIED PHYSICIAN CORONERS PHYSICIAN •W 'TIIJNTY NTTORNE
<br />Jeffrey K. King, M.D., 72"; N Custer Aye., Grand Island, NE 68803
<br />M
<br />M
<br />32. REGISTRAR
<br />325 DATE FILED BY REGISTRAR 4 6 Ow en .
<br />NOV 1 8 2004
<br />
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