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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<O 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 />
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