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<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 SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />2 0 2 0 0 13 8 4 RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />7/18/2019
<br />LINCOLN, NEBRASKA
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Lawrence Owen Rolofson
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (No., Day, Yr.)
<br />July 11, 2019
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />I
<br />' 507-24-2708..
<br />6a. AGE Last Birthday
<br />{Yrp
<br />93
<br />p ob. FACILITY-NAMMa of not inn+Gtuticn, give street and .r..urribc: t
<br />tit
<br />zEs Brookefield Park
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<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />St. Paul 68873
<br />8a. RESIDENCE -STATE
<br />Nebraska
<br />s-rkEtt AND NUMBER
<br />1405 Heritage
<br />Sb. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />September 5, 1
<br />925
<br />OTHER ® Nursing Home/LTC 0 Hospice Facility
<br />❑ r .cedenrs Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Howard
<br />9b. COUNTY
<br />Howard
<br />9c. CITY OR TOWN
<br />St. Paul
<br />9d.
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68873
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married ❑ Never Married
<br />0 Married, but separated Widowed 0 Divorced 0 Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Iona Runge
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Lawrence Owen Rolofson Sr
<br />12. MOTHER'S -NAME (First, Middle,
<br />Nathalie Mieth
<br />Maiden Surname)
<br />13. EVER IN U.S. ARMED FORCES?
<br />(Yee,' No, orunk.) No
<br />Give dates of service If Yes.
<br />14a. INFORMANT -NAME
<br />Gala Wurdeman
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />16. METHOD OF DISPOSITION'
<br />® Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />Removal ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Gwen K. Hyronemus
<br />ib. LICENSE NO.
<br />1448
<br />16c. DATE (Mo., Day, Yr.)
<br />July 15, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Mt. Pleasant Cemetery
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />ADfel Funeral Home 1123 W. 2nd. Grand Island. Nebraska
<br />CITY / TOWN
<br />Cairo
<br />CAUSE OF DEATH (See instructions and examples)
<br />16. 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 />respiratory meet, or ventrktihrfibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Chronic Respiratory Failure
<br />disease or condition resulting
<br />("death)
<br />death)
<br />DUE TO, OR AS. A CONSEQUENCE OF:
<br />Bvauentjaly net condition*, if : blChronic Obstructive
<br />_ .monary Disease
<br />any, leading to the cause fisted
<br />on line al.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury dud initiated
<br />the svente returning in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />Alzheimers Dementia, Congestive Heart Failure, Hypertension
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />❑. Not pregnant, but pregnant within 42 days of death
<br />© Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown N pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />2:
<br />INJURY AT WORK?
<br />❑YES ONO
<br />21a. MANNER OF DEATH
<br />El Natural ❑ Homicide
<br />❑ Accident 0 Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian'
<br />❑ °titer(Specify)
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Days
<br />onset to death
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES RI NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF: DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />(4
<br />v 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />N
<br />0
<br />.S'
<br />8
<br />el
<br />CITYITOWN
<br />STATE
<br />ZIP CODE
<br />23*. DATE OF DEATH (Mo., Day, Yr.)
<br />July 11, 2019
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />July 15. 2019 08:39 AM
<br />23d. To the bast of my knowledge, death occurred at the time, date and place
<br />and due to the causeis) stated. (Signature and Title)
<br />Jared Kramer, MD
<br />25. DID' TOBACCO; USE CONTRIBUTEtTO THE DEATH?
<br />0 YES �`NO t] PROBABLY 0 UNKNOWN
<br />SIGNATURE
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jared Kramer, MD, 1113 Sherman St., PO Box 406, St. Paul, Nebraska, 68873
<br />.,aa. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ONO
<br />28a. REGISTRAR'S
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO ❑ YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr,)
<br />July 15, 2019
<br />
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