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<br />STATE OF NEBRASKA
<br />tttt�Wara 4.Y�IpI,IR1ft1AlFJE Y&�YAYNta s'r3yG7l
<br />W'HL�IY THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, TT CERTIFIES THE DOCUMENT BELO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMANSERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL. RECORDS
<br />DATE OF ISSUANCE
<br />4/27/2023'`
<br />LINCOLN, NEBRASKA
<br />SARAH BOHNENKAMP ` T
<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 />1. DECSDEND:.S-NAME tF.irst, MIddle, Last, Suffix)
<br />Davld ii awrence.. Larson
<br />4 CITY AND B ATE ORTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Broken Bow, Nebraska
<br />T EOCiAL SEIURITY NUMBER'
<br />505 36-9738
<br />Se. AGE - LasttBirthda t
<br />(Yrs.)
<br />88,;,.
<br />8.
<br />8b.fACILITY-NAMEif not Institution, give street and number)
<br />3440 Graham Avenue
<br />8o:,'CITY OR T!I(OF DE4T
<br />Grand island 88803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />>1d. STREET AND NUMBER
<br />3440 Grei�anl AvelUe
<br />Iude Zip Code)
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ htpatlent
<br />❑ ER/Outpatient
<br />❑ DOA
<br />•
<br />9b. COUNTY
<br />hall
<br />10a MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated Widowed 0 Divorced 0 Unknown
<br />•
<br />11, FATHER S NA. ME riot, :0400, ,•.• suffix)
<br />Jahn Larson Sr
<br />13 : EVER IN U s ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) Yes 04/09/1957-04/08/1959
<br />16. METHOD Of DISPOSITION
<br />a Burial ❑Donation
<br />0Cremat( OEntrmibment
<br />13 Rrimoval ❑ O#lier (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />23 05435
<br />3. DATE OF DEATH (Ito., Cley,.Yr.)
<br />April 12, 2023
<br />6. DATE OF BIRTt1(Mo., bey, Yr.) .;
<br />July 14, 1934......................
<br />OTHER 0 Nursing Home/LTC
<br />Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />°spice Facility
<br />8p. INSIDE CrjTY1JMITS
<br />. YES Q NO
<br />10b. NAME OF SPOUSE (Prat, Middle, Last, Suffix) If wife, give maiden name
<br />Terry Lou Meves
<br />i12. MOTHER'S -NAME (First, Middle, Maiden
<br />Louis Monteyena
<br />14a. INFORMANT -NAM
<br />Shirley Holmes
<br />16a. EMBALMERSIONATURE
<br />Laurie D. Sheffield
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand island City Cemetery
<br />lTa.:.FUNERALHc04E NAME AND MA LING ADDRESS (Street, City or Town State)
<br />All Faiths uneral Nome, 2929 S. Locust Street, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />1397
<br />CITY / TOWN
<br />Grand Island
<br />roams)
<br />14b. REjATIONSftP TOOECEDENC:i
<br />Friend
<br />16c. DATE (Mo., Dey, Yr.),.
<br />April 18,: 2023
<br />CAUSE OF DEATH (See Instructions and examples)
<br />18. PART I. Enter the chain of events- 41seases, Injuries, or complication -that directly caused the death. DO NOT enter terminal events such aa cardiac arrest,
<br />respiretory wrest, or ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />MOM S ( a) Cardiac Arrest
<br />d19Qpse of eoddIEidn OduIBAg
<br />to death),
<br />17b Z(pt
<br />APPROXIMATE INTERVAL
<br />onset 10 death'
<br />;'Minutes
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b) chronic obstructive pulmonary disease
<br />any, leading to the cause listed
<br />fie a
<br />onset to death
<br />Minutes
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Miter taetritli .ONO CAUSE D)
<br />(dlegMorinjuiythet Initiated
<br />Alm events resulting;in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />onset to death
<br />18. PART 8:' OTHER SIGNIIFICANT CONDITIONS-Condions contributing to the death
<br />.20. IE FEMALE.;=
<br />Not pregnanlwfattapast year'
<br />Pregnantat Saha of denfi
<br />u" iNat pregnant, bud ptegiwnt within 42 days of death
<br />❑ -,Net pregnatibbut pregnant 43 days to.1 year before death
<br />❑ Unknown lrtegll>RM Within the peat year
<br />t not resulting: f0 ttte underlying cause given in PART L
<br />'22a. DATE OF'.INJURY (MO-, Day, Yr.)
<br />22d. INJURY AT;WORK?
<br />21a. MANNER-O�yF DEATH
<br />® iJ Natural 14IMNIda
<br />❑ Accident ❑ Pemifirhg imveatigetlon
<br />❑ suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLA'
<br />22e, DESCRIBE HOW INJURY OCCURRED
<br />Tltitd`oF(t+(Jtiny- STREET & NUMBER, APT.NO.
<br />23a.„'DATE OF DEATH (Mo.,,Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />21b. IF TRANSPORTATION INJURY
<br />t.l tirlrer/Operator
<br />© Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />19. WAS miltOtp4 EXAMINER
<br />OR CORONER:cXNJTAQTED?
<br />®YES El NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YEs No
<br />21d. WEREAUTOPSYANDINGSAVAN.ABLE
<br />TO COMPLETE CAUSE` OF DEATH?
<br />0 YES ❑ NO
<br />:OFiNJURY.Athome farm, street, factory, office building, construction eKe,'99
<br />CITWTOWN
<br />23c. TIME OF DEATH
<br />bd. To the beat of my knowledge, death occurred at the time, date and place
<br />and due telhe Causes) stated. (Signature and Title)
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />April 20, 2023
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />Unknown
<br />24d. TIME PRONOUNCED DEAD
<br />06:58 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />2. 2023
<br />[ 24L on the basis of examination and/or Investigation, In my opinion Mathawvrtod at
<br />ff
<br />MO** date andplace and due to the cause(e) stated. (Signapam end ulte);
<br />Benjamin W Shanahan, Deputy County: Attorney
<br />26. DID TOBACCO USE;CONTRIBUTE TO THE DEATH? 26a. HAS GROAN OR TISSUE DONA110.N.BEEN CONSIDERED?
<br />0 YES ❑ NO i7D PROBABLY I ] UNKNOWN 0 YES NO
<br />21,',',.:,:,, ME„ 1TTLE AN%1 A... REBS OF CERTIFIER (Type or Print
<br />Benjamin IN Shanahan, Deputy County Attorney, 231 South Locust St Grand istand,;Nebraska, 68803
<br />+286.REGISTRAR'S SIGNATURE �n 28b. DATE FILED BY REGISTRAR (Mo., Day Yr.)
<br />Lr G�?.r�L April 24, 2023
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable N 26a is NO YES
<br />NO
<br />
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