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STATE OF NEBRASKA <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE, WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SBCWIL0WHICIi <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />OCT 0 3 2007 <br />202107018 <br />200709681 <br />LINCOLN, NEBRASKA HEAL' <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICESfIIi <br />CERTIFICATE OF DEATH <br />1 To Bo CompletedMVutfled by: FUNERAL DIRECTOR <br />1. DECEDENT'S -NAME ( First, Middle, Last, Sulflx) <br />' Terry Lou Larson <br />2, 'V <br />'' , r <br />L c 2QA � <br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH <br />6a. AGE -Last Birthday <br />5b. UNDER I YEAR <br />5c. 1.1 i <br />1. <br />.i 1611). -.Gary. Yr).9. <br />Grand Island, Nebraska <br />(Yrs.) <br />71 <br />MOS. <br />DAYS <br />HOURS <br />-. M <br />��� ' <br />r�_. w <br />- } <br />' wombat; r <br />23; 19351 <br />7, SOCIAL SECURITY NUMBER <br />507-36-3491 <br />8a. PLACE OF DEATH <br />HOSPITAL: til Inpatient OBES 0 NursingHom&LTO CI Hospice Faddy <br />8b. FACILITY -NAME (I1 not Institution, give street and number) <br />Saint Francis Medical Center <br />❑ ER/Outpatient 0 DecedenreHame <br />0 co% 0 OMr(Spedy) <br />80, CITY OR TOWN OF DEATH (Include Zlp Code) <br />Grand Island 68803 <br />8d. COUNTY OF DEATH <br />Hall <br />ea. RESIDENCE -STATE <br />Nebraska <br />8b. COUNTY <br />Hall <br />en CITY OR TOWN <br />Grand Island <br />9d. STREET AND NUMBER <br />3440 Graham Ave. <br />9e. APT. NO <br />91. ZIP CODE <br />68803 <br />9g. INSIDE CITY LIMITS <br />O YES 0 NO <br />10a. MARITAL STATUS AT TIME OF DEATH J Married ❑ Never Marned <br />0 Marned, but separated ❑ Widowed ❑ Divorced 0 Unknown <br />10b. NAME OF SPOUSE (First. Middle, Last, Suffix) If wile, give maiden name. <br />David Larson <br />11. FATHER'S -NAME (First, Middle, Last, Suffix) <br />Irvin P - Meves <br />12. MOTHER'S -NAME (First, Middle, Malden Surname) <br />Ruby Terry <br />13. EVER IN U.S. ARMED FORCES? Give dates of seMcellyes. <br />(Yes. no, orunk.) No <br />14a. INFORMANT -NAME <br />David Larson <br />14b. RELATIONSHIP TO DECEDENT <br />Husband <br />15. METHOD OF DISPOSITION <br />l Burial 0 Donation <br />16a. BALMER-SIGU <br />�/VL ��/•O <br />16b. UCENSE NO. <br />7 / <br />16c. DATE (Mo., Day, Yr. ) <br />September 22, 2007 <br />0 Cremalon CI Entombment19(EMETERY, <br />❑Removal ❑ Other (Specify) <br />CREMATORY OR OTHER LOCA1N CITY / TOWN STATE <br />Grand Island City Cemetery Grand Island Nebraska <br />17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, Cly or Town, Stals <br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska <br />17b. Zip Code <br />68801 <br />r <br />RAUSE OF DEATH (See Instructions and examples) <br />1 &('' To Be Completed by: CERTFER <br />18. PART I. Enter the chain of events--mseasees, Injuries, or complications --that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL <br />respiratory arrest. or ventricular IlbdllaUon without showing the elology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. I <br />IMMEDIATE CAUSE: I onset to death <br />• <br />MMIEDIATECAUBE(Fhal (e) <br />dIweeacand1lonresulklg DUETO,ORASAC SEOUENCEOF: I onset lodeath <br />ki deals) <br />Sequentially Netcondmom, II N) <br />any,MINN lethe Cali" kted DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death <br />on Um a. <br />Firer M UNDERLYNG CAl18E <br />(Mum or Injury that Inflated (c) <br />the events resulting haalr) DUE TO, OR AS A CONSEQUENCE OF: I onset todeath <br />LABT <br />(d) <br />18. PART 11. OTHER SIGNIFICANT CONDITIONS-Condtlons contributing 10 the death but not resulting In the underlying cause given in PART I. <br />�LSU� , (1' C •- t- <br />, <br />19. WAS MEDICAL EXAMINER <br />OR CORONER CONTACTED? <br />❑ YES NO <br />20. IF FEMALE: <br />ANot pregnant within past year <br />0 Pregnant at time of death <br />21a.YYYNEROFDEATH <br />brral 0 Homicide <br />❑ Acoldent❑ Pendng Investigation <br />21b. IF TRANSPORTATION INJURY <br />❑Driver/Operator <br />CI P ager <br />21c. WAS AN AUTOPSY PERFORMED'? <br />u <br />❑YES l0 NO <br />0 Not pregnant, but pregnant within 42 days of death <br />0 Not pregnant, but pregnant 43 days to 1 year belore dalh <br />❑ Unknown IIpregnant wltMnthe past year <br />❑ Weide❑Could not be debrtnkred <br />❑ Pedestrian <br />0 Other (Specify) <br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO <br />COMPLETE CAUSE OF DEATH? `•. _ <br />0 YES 0 N <br />22a. DATE OF INJURY (Mo., Day, Yr.) <br />22b. TIME OF INJURY <br />m <br />22c, PLACE OF INJURY -AI home, farm, <br />street, factory, office bulling, construction <br />site, etc. (Speedy) <br />22d. INJURY ATWORK? <br />0 YES ❑ NO <br />22e. DESCRIBE HOW INJURY OCCURRED <br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE <br />ail <br />23a. DATE OF DEATH (Mo., Day, Yr.),, <br />September 20, 2007 <br />pz <br />24a. DATE SIGNED (Mo., Day,Yr.) <br />24b. TIME OF DEATH <br />m <br />16r- <br />23b.DATE SIG 1ED(Mo .,Day.Yr.) <br />23c. TIME OF DEATH <br />1_ > <br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) <br />24ILTIME PRONOUNCED DEAD <br />23d. To the best of my knowledge, death occurred at plethm, <br />Eand due to Inc cause(s) stated. (Signature and Title) <br />I!. a <br />date and place <br />1 i Z <br />3 o C $ <br />8r <br />24e. On M bade 01 examination and/or inveatipotion, In my opinion death occurred at <br />M ams, date and pias and due to M cause(s) stated. (Signature end TIM) <br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />0 YES0 0 PROBABLY 0 UNKNOWN <br />26a. HAS ORGAN OR TISSUE DOONATION BEEN CONSIDERED? <br />❑YES )!tit NO <br />26b. WAS CONSENT GRANTED? <br />Not Applicable If 26a Is NO 0 YES CI NO <br />27. NAME, TITLE AND ADDRESS OF CERTIRER (PHYSICIAN, CORONER'S PHYSICIAN ORCOUN TTORNEY) (typeorPnnt) <br />Heather Hockman, M.D. 3016 W. Faidley Ave., Grand Island, NE 68803 <br />P <br />28a. REGISTRAR'S SIGNATURE <br />e <br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) <br />SEP 2 4 2007 <br />