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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 NEBRASKihrYkPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR-1TITALtIRSStORDS.
<br />DATE OF ISSUANCE
<br />02/12/2016
<br />LINCOLN, NEBRASKA
<br />0
<br />202008614
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGIS`
<br />DEPART! ENT OF HEALTH AND 0"
<br />HUMAN SERVICES 1•
<br />�f>
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />16 20580
<br />ITo Be CompletedNerilled by: FUNERAL DIRECTOR f
<br />- 1. DECEDENTS -NAME (Fiat, Middle, Last, Suffix)
<br />Susan Jean Puhalla
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo.Diy.Yr.)
<br />January 31, 2018 .
<br />4 CRY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />K AGE1rt BIrnday
<br />5b. UNDER 1 YEAR
<br />Eo. UNDER I DAY
<br />S. DATE OF BIRTH (Mo., Day. Yr.)
<br />Omaha, Nebraska
<br />(Yrs.)
<br />69
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />September 3, 1948
<br />7. SOCIAL SECURITY NUMBER
<br />s4 PLACE OF
<br />Haleatli.
<br />DEATH
<br />0 bwsmeM Numlag
<br />508-64-4423
<br />Qng&I El None/LTC 0 Hospice Faithity
<br />Sb. FACIUTY4IAME (V not Instiludon. Sive street and nsnlbst)
<br />Wedgewood Care Center
<br />0 ERIOupat1sm 0 Decedent. Hare
<br />❑ °OA ❑O1I"'(sP""")
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 88803
<br />Sd. COUNTY OF DEATH
<br />Hall
<br />So. RESDENCE4TATE
<br />Nebraska
<br />S0. COUNTY
<br />Hall
<br />Sc. CITY
<br />Grand
<br />OR TOWN
<br />Island
<br />Ed. STRUT AND NUMBER
<br />1110 S. Eugene Street
<br />Ss. APT. NO.
<br />W. ZIP CODE
<br />88801
<br />S` MODE CITY LIIBTS
<br />®Vas ❑ Na
<br />los. MARITAL STATUS AT TIME OF DEATH M Maenad 0 Neva M100. NAME OF SPOUSE (F
<br />oriel
<br />❑ Married, but
<br />MaklotMakLast, SuBIa) Wolfe, Smaidenone
<br />e maiden n.
<br />sepaaled ❑ ""lowed 0 Diw„ed ❑ Unknown Robert Emil Puhalla
<br />11. FATHERS -NAME (Plat. MINK Lase, Suffix)
<br />12. MOTHERS
<br />-NAME (Rot, Middle, Malden Suncor)
<br />Frank Davis
<br />Maude
<br />Moran
<br />13. EVER IN U.S. ARMED FORCES? Give dabs of woke N Yee.
<br />(Yee, No, 0, ural) No
<br />144 INFORMANT -NAME
<br />Robert Emil Puhalla
<br />140. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />1g. METHOD OF DISPOSITION
<br />❑OWD ❑on.w.
<br />ISa. EMIALMERJO(GNATURE
<br />Not Embalmed
<br />lib. UCENSE NO.
<br />1Sc. DATE (M0. Day. Yr.)
<br />February 4, 2016
<br />®e....lee ❑e.wr.°
<br />Rd. CEMETERY, CREMATORY OR OTHER LOCATION
<br />CITYITOWN STATE
<br />❑,,,,,,,,d ❑ nisemawato
<br />Central Nebraska Cremation Services
<br />Gibbon Nebraska
<br />174 FUNERAL HOME NAME AND MAIUNG ADDRESS (Sebe. City or Town, Stab)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />170. Zlp Coda
<br />68801
<br />ITo Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See Instructions
<br />and examples)
<br />1e. PSM' 15r.erdv of•TogMseM•a..w..Nodes. Oro..vaown.Dot shay mood Ow MOD. 0° NOT wow UM.
<br />rrSI.tay rnn, or vee1rM..r fSecaon without domino Or ald.wy. DO MDT AMEREVIAT4 Enter only a sorer on
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Plod
<br />� ) condition 1aau lbig a) rn l LAk-L (N 0.`., 4: , \ LA.4.-
<br />sora was as wow on.t
<br />e now Add M/b.nr eam r noroom.ry.
<br />APPROXIMATE INTERVAL
<br />onset to dod.
<br />42 kr 5.
<br />DUE TO, OR ASA CONIU E OF:
<br />EQ
<br />E.4uen°Wy Net conditions. N.
<br />any. M Sflg b MHO HO Modb) C I Pat' tit 1 ` y-e_h ra CLllliliv - 1.0
<br />1T+,p t. mom'• a); A -E.4-1 •L .
<br />onset le WMA
<br />Z yrs •
<br />on me 4 DUE TO, OR ASA CONSEQUENCE OF:
<br />ELM., Si. UNDERLYING CAUSE c)
<br />Klemm or injury that Initiated
<br />1
<br />most be dean
<br />Si. s.rna remling In dean) DUE TO, ORAS A CONSEQUENCE OF:
<br />LAST
<br />_ d)
<br />ansa be death
<br />1S. PART A OTHER SWNIRCANT CONOff OtSCOMtiar to do Man but In
<br />Dordrlloillng net resetorq
<br />Si. underlying came Oven In PART L
<br />111. WAS MEDICAL. EXAMINER
<br />OR CORONER CONTACTED?
<br />DYER tg No
<br />20. W FEMALE:
<br />ElNat
<br />214 MANNER OF DEATH
<br />21b. IF TRANSPORTATION INJURY
<br />211 WAS AN AUTOPSY PERFORMED?
<br />pregnant within pan yadx
<br />❑ H«nlewe
<br />0 2I 5rOPetla
<br />❑ res Rpm
<br />❑PrepwM at I.e of deadeathAMeM
<br />❑Netpngnodwithin, but 42 days of dean
<br />0 Pendine Im.sdgatlmh
<br />0 Suicide 0 Could not be determined
<br />0 Paaaanger
<br />0 Pedestrian
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />pregnantwithin
<br />ONOP•omen% but
<br />TO COMPLETE CAUSE OF DEATH?
<br />pregnant 43 days to 1 year before dean
<br />❑Unknlown N pregnant wIIMn Si. past year
<br />❑ Omer (Specify)
<br />❑ def Ism
<br />224 DATE OF INJURY (Mo., Day, Yr.)
<br />220. TME OF INJURY
<br />m
<br />22c. PLACE OF IUURY.At hams
<br />fMq sweet, fec/ry, ons building, eansbnatisn site, etc. (Specify)
<br />224 INJURY AT WORN?
<br />❑Yes 0 N
<br />224 DESCRIBE HOW INJURY OCCURRED
<br />22,. LOCATION OF INJURY - STREET S NUMBER, APT. NO. CITY/TOWN
<br />STATE ZIP CODE
<br />B
<br />274 DATE OF DEATH (Mo., DIG. Yr.)
<br />.1(1r-‘1ary 31 .a01 Le
<br />.
<br />24. DATE SIGNED (Mo., Day Yr.)
<br />_
<br />240. TWE OF DEATH
<br />m
<br />I220.
<br />I
<br />DATE SIGNED (Ver Day, Yr.)
<br />d7S• Ps- lG
<br />224 TWE OF DEATH
<br />�� m
<br />041
<br />2k. PRONOUNCED DEAD (Mo., Day. Yr.)
<br />240. TWE PRONOUNCED DEAD
<br />m
<br />2244 To the beet of my le1Dn•I•dIS4 the ons, db and
<br />ID O
<br />S4.On
<br />S
<br />le
<br />at pada
<br />and to Si. caws(*) ateted. and LINO
<br />3 g§
<br />Z
<br />the basis of onAnaSmn andler hiviatigation, In ray death occurred
<br />at the time, dab and piece and dna to a staled. and TIB)
<br />2g. DD USE TO THE DEATH?
<br />*RYES 0 NO PRONELY 0 UNKNOWN
<br />254 NAf ORGAN OR TISSUE DONATION OWN CONSIDERED?
<br />❑ YES • , NO
<br />250. WAS CONSENT GRANTED?
<br />Not AppIcable I leak NO ❑ YES - 0 ND
<br />27. NAME. TITLE AND ADDRESS OF CERTIRER (Ty.. or NM) Larry L. H_a�n G. MD ' 1,, Ce
<br />3011, w -eat dhks)�ktre Or rna Ts1a • '. ". Le:'o3 4kUh.S.Ph i�2 0 k cal-& Ce -
<br />F
<br />2S4 REGISTRAR'S SIGNATURE
<br />► , , "
<br />250. DATE FILED BY REGISTRAR (Ms. Dar, Yr.)
<br />FEB 8 2016
<br />
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