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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF TF/E NEBRASKA DEPARTMENT OF HEAL4D$zi
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH T F NE$R*SJA.7
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIT
<br />DATE OF ISSUANCE
<br />DEC 19 ZOII
<br />dr ,•,r
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND H MAN SERtt`
<br />V E� r''
<br />f �RTI�lf ATfr AF 11FOTN . ":
<br />LINCOLN, NEBRASKA
<br />To Be CompletedNerifled by: 4INERAt'DIRECTOR
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix) --• • •• �_• • • - "-
<br />Jerry Lee Faustian
<br />(2.ISl;X Y, t' l
<br />Male4
<br />t D11)/(
<br />y �7 , ` 4,421311 . '
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />t e. AGE -Last Birthday
<br />5b. UNDER 1 YEAR:
<br />6°, UNDER.INDAY a
<br />ILI • i Tata*. Day, Yr.)
<br />Grand Island, Nebraska ,
<br />(Yrs.)
<br />72
<br />MOS.
<br />DAYS
<br />HOURS
<br />'MINE'
<br />e
<br />January 22, 1939
<br />7. SOCIAL SECURITY NUMBER
<br />505-42-4025
<br />8a. PLACE OF DEATH
<br />12256161.: ® inpatient QTt &O Nursing Homs/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (d not Institution, give skeet and number)
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA ❑ OIhe(SPe Y)
<br />Veterans Affairs Medical Center
<br />8e. CITY OR TOWN OF DEATH (include Zip Code) -
<br />Grand Island 68803
<br />9d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />91s. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />657 Martin Ave
<br />9e. APT. NO.
<br />1 9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® Ye. 0 No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Marled, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give madden name.
<br />Marilyn Ann Lessig
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />John Henry Paustian
<br />12. MOTHER'S -NAME (FIrst, Middle, Maiden Somme/
<br />Olga Elizabeth Rohweder
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service NW*.
<br />(Yes, No, or Unk) Yes 06/06/1957-04/15/1960
<br />14a. INFORMANT -NAME
<br />Marilyn Ann Paustian _
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />Dhabi Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />December 14, 2011
<br />BilCrenudion ❑Entombment
<br />❑R.mwM ❑Dthegsl,.exy)
<br />-
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />88801
<br />To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART 1. Enter the ammo oI wane -diseases, injuries, or complications. that directly caused the death. DO NOT enter btmlml events such as cardiac arrest
<br />APPROXIMATE INTERVAL
<br />respiratory amen, or ventricular abNletion without showing the etiology. DO NOT ABBREVIATE Enter only one alum on • grte. Add additional lines ti necessary.
<br />IMMEDIATE CAUSE:
<br />MEDIATE CAUSE (Final
<br />indeasorconditionreaultlng a) C�cUlo \k\mo1101TA.` Q!\ VAc e.
<br />M death) �l U
<br />onset to death
<br />DUE TO, OR AS A CONS QUENCE OF: l``
<br />Sequentially list conditions, It .`y, .`}
<br />any, leading to the cause listed b) Con t•AIll C, \\lac 1 c `Q\1\A `L • Act yAnct ci En S41w3.e
<br />onset to death
<br />on Ulna a. DUE TO, OR CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE e) n oee•I,C\ac\. is, C\t,(.`yZNS \SCD,.<t_
<br />(\f -
<br />onset to death
<br />(disease or Injury that Initiated
<br />the events resulting In death) DUE TO, OR AS A CONBEQU E OF:
<br />LAST
<br />d) I�oYYls__ .k•encsSts
<br />onsetto W
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause givers In PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES 'V NO
<br />20. IF FEMALE:
<br />['Not pregnant within past year
<br />21s. MANNER OF DEATH
<br />Igitlatural 0 Homicide
<br />21b. IF TRANSPORTATION INJURY
<br />0 Drive/Operator
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES _'gm
<br />❑Prognant at dna 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 />['Unknown N pregnant within the past year
<br />❑Accident ❑Pending InvestlSWon
<br />0 Suicide 0 Could not be dstemiln.d
<br />0 Peatengar
<br />0 Ped. trlan
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />•
<br />22a. DATE OF INJURY (Mo., DIY, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At home, fano, •treat factory, odics building, construction Ws, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />o YES *0
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET 8 NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />kW
<br />23a. DATE OF DEATH (Mo.,, Day, Yr.)
<br />'lCC Qc4.\Hf to atoll
<br />Z
<br />II
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OP DEATH
<br />m
<br />st)o
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />pec bac lit, - 0�
<br />23c. TIME OF DEATH
<br />al; 40 p.m
<br />�tI
<br />p}
<br />Y
<br />$soro<0
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />V
<br />o p
<br />I.-IIJ .
<br />-et
<br />23d. T at of my k • - • go, ds ✓- cored at dM time, date and place
<br />o the , %� end tie)
<br />..
<br />d1
<br />2 Z
<br />x C
<br />60
<br />24e. On da bells of examination and/or Investigation, In my opinion death occumd
<br />at the time, date and place and due to the usa(s) stated. (Signature and Title)
<br />gc.
<br />26. DID TOBACCO USE • NTR = ' TO DEATH?
<br />`�'\ ES 0 NO S ' • : BL(0UNKNO
<br />- , •
<br />HAS ORGAN OR ON BEEN CONSIDERED?
<br />❑ YES r1 •
<br />266. WAS CONSENT GRANTED?
<br />Not Applicable M 28a Is NO 0 YES NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, • - •PHYSICIAN OR COUNTY ATTORNEY)
<br />oX(;\{antw�eVitz'M.0. YAmc &aol 6c octivIll C�co,nc) `'cicn
<br />(Type or Print)
<br />Nit' bFct 4 lv8$Q'
<br />211. EGISTRAR'S SIGNATURE
<br />A(410,104. 1.
<br />28b. DATE FILED BY REGISTRAR4M.., Day, W.)
<br />DEC 15 2011
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