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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DePARTF H5ALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR-t1T,aL
<br />DATE OF ISSUANCE
<br />JUN 0 4 2015
<br />201907386
<br />LINCOLN, NEBRASKA HOSAIV+S
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN 84^��1je1 ry��y Ri
<br />ArnTerIA ATr Aur nr ATIJ �^M.�Jl
<br />To Be CompletedNerffied by: FUNERAL DIRECTOR 1
<br />VGR 111 -AVN 1G it MrGM 1
<br />1. DECEDENT'S.NAME (First, Middle, Last, Suffix)
<br />2. SEX ) . A,
<br />Gary LeRoy Larsen
<br />Make. '''.:%'411k."'
<br />. • ",. t .
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ba. AGE -Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER f DA} _
<br />5ii llo- 'Dry,, Yr.) -.
<br />Grand Island, Nebraska
<br />(Yes.)
<br />63
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />September 17, 1951
<br />7. SOCIAL SECURITY NUMBER
<br />505-64-1536
<br />9a. PLACE OF DEATH
<br />HOSPITAL 0 11131818ffi ammo Nursing Home/LTC 0 Hospice PacIIMy
<br />Bb. FAC1UTY-NAME (t not Institution, give street and number)
<br />510 E, 7th Street
<br />0 ER/Oulpattent ® Decedent's Hanle
<br />0 DOA ❑ 011101IBP5 Y)
<br />Grand Island 88801 I Sc. CITY OR TOWN OF DEATH (Include Zip Cods) ,
<br />ed COUNTY OF DEATH
<br />Hall.
<br />8a. RESIDENCE -STATE
<br />Nebraska
<br />eb. COUNTY
<br />I Hall
<br />8a CITY OR TOWN
<br />Grand Island
<br />Sd. STREET AND NUMBER
<br />510 E, 7th Street
<br />8e APT. NO.
<br />I
<br />W. ZIP CODE
<br />I 68801
<br />se. INSIDE CITY UNITS
<br />®v.• 0 NGo
<br />10a. MARITAL STATUS AT TIME OF DEATH gl Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Mldd1s. Last, Suffix) If wife, give maiden name.
<br />Michele Shafer
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Harvey 0 Larsen
<br />12. MOTHER'S -NAME (Fhst, Middle, Malden Surname)
<br />Gladys Lucille Schliecher
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes.
<br />(Yes, No, or Ink., Yes 09/23/1969-06/25/1970
<br />14a. INFORMANT -NAME
<br />Michele Larsen
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑Ba"" ❑Donabof
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />18c. DATE (Mo., Day, Yr.)
<br />044•- 4- 0016
<br />®Demotion ['Entombment
<br />❑Romovol 00IIrrl6Mclfy)
<br />t6d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />Westlawn Memorial Park Crematory Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, Stab)
<br />Livingston -Sondermann Funeral Home, 1301 N. Webb Road, Grand Island, Nebraska
<br />17b. ZIP Code
<br />l 68803
<br />l
<br />To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART 1. Enter Me IM6n dwantr- discus, !Merles, orcompiudem-div drossy meed the drat. DO NOT enter %mknl events moth r battle. welt, ` APP*ZOOATE sitzawe...'..
<br />mmentory sweet, orvanMcW rMrMeaon Mem* sharing the etiology. DO NOT ABBREVIATE. Eimmady an emir en o lbw. Add oddWawl atm I mererry.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Fled
<br />dleaa t or condition muffing a) n rd 1 b AtLP;C 0. Q c i \)A,\�ct-
<br />in death) th {('�
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF: \
<br />Sequentially list conditions, IT b) t� \ k./LSany, leading to the cause listed '1 A n e l 0:, t-
<br />oneat to death
<br />ontines. DUE TO, OR AS A COI EQUENCE OF:
<br />Enter the UNDERLYING CAUSE D, Diabetes, High Blood Pressure; Dialysis started 06/2012
<br />onset to dose
<br />(disease or injury that initiated
<br />the awnb muldng in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />' d)
<br />onset to death
<br />18. PART IL OTHER SKGNNIFICANT CONDITIONS -Conditions contributing to the death but not mulling In the underlying cause given In PART L
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES X NO
<br />20. F FEMALE:
<br />❑Not pregnant within past year
<br />21a. MANNER OF DEATH
<br />0 Homicide
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />21a WAS AN AUTOPSY��,/� PERFORMED?
<br />0 YES
<br />❑Pregnant at tuns of death
<br />❑ Not pregnant, but pregnant wktdn 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑urdnowa 11 pregnant within tibpast year
<br />0 Acdded 0 Pending investigation
<br />0 Suicide 0 Could not be determined
<br />0 Passenger
<br />0 Pedestrian
<br />0 Mar (SPedfy)
<br />21d. WERE AUTOPSY FINDINGS AVAWIBLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 122b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At horns, Tarn, sheet, factory, office building, construction site, etc. (Specify)
<br />22t INJURY AT WORK?
<br />❑ YES ❑ No
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />-
<br />22f. LOCATION OF INJURY - STREET It NUMBER APT. NO. CITYITOWN STATE ZIP CODE
<br />'td'
<br />23a. DATE OF DEATH (M0. Day, Yr.)
<br />A\ x\1 Q3 ,QOl�
<br />.11.28
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />~'
<br />1Ugg
<br />23b. D SIGNED (Mo., Day, Yr.) ,
<br />AQC,1 Q4 db16
<br />23c. TIME OF DEATH
<br />1:36, ix,.
<br />Y
<br />S
<br />E.a o
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d TIME PRONOUNCED DEAD
<br />m
<br />12 W
<br />23d. To ar beat of my lanowledpe, death occurred at the time, dab and place
<br />and dee to the dauae(s) stated. (SlgnsWn and Tito)
<br />8 it z
<br />. C O
<br />24e. On the basks of examination a dfor Investigation, In my apkdon death occurred
<br />at the time, dab and place and dee tote causes) stated. (Slgnetwe and Tito)
<br />25. DID TOBACCO USE CONTRIBUTE TO E D TH?
<br />❑ YES 0 NO 0 PROBABLY UNKNOWN
<br />26a. HAS ORGAN OR 11 -. E , e NATION BEEN CONSIDERED?
<br />0 YES h• NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />7Ne\'ticks C \r•AC\• 9N -C \4/4M 49,01 N Ocpr, t,.el\ P-rarc17,_ cxed
<br />NPkec 0.(nn()3
<br />P
<br />28a. REGISTRAR'S 8IQNA RE
<br />ifriefAk./J. ' l r .
<br />26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />APR 2 9 2015
<br />
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