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<br />WHEN1111.THISr COPY CARRIES THE RAISED SEAL OF 7HHE STE OF NEBRASKA, IT
<br />CERTh IES ThE • DOCUMENT BELOW • 'TO SENA TRt1E COPY DTAF THE ORIGINAL -RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS'THE LEGAL DEPOSITORlr FOR .VITAL RECORDS
<br />TANT STATE REGISTRAR.
<br />n )) (� /� y rq RUSSE ,L FOSLER,
<br />2 U L G 3 L V/ DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />DATE OFI$SLI4NCE
<br />D/3O/2O1t "`. .
<br />LIN COLPI, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT'S -NAME (First, : MidcAe, Last; Suffix)
<br />Stacia Ann Larson
<br />3t
<br />`9d STREETANDNUMBER
<br />2404 W. Charles
<br />,v
<br />AND Sl TE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand.(slatsd, Nib's
<br />5a AGE Lasf Birthday
<br />5b. UNDER:1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY.
<br />i94012, .
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH"(Mo., Day, Yi.4
<br />September 23, 2019.
<br />6. DATE OF BtRTH.(Msak
<br />February 17,943
<br />7. SOCIAL SECURITY NUMBER
<br />505.-52-344.7.
<br />8b FACILITY NAME (11 (1ot 11'1stitutlon, give street and number) -
<br />CHI Health 51 Fro(lic)s
<br />8c. CITY OR TOWN OF DEATHQhtchule Zip Code)
<br />Grand. Island 68803
<br />9a RE$IDNCE4P E
<br />Nebraa ..... .
<br />9b. COUNTY
<br />Half
<br />4Qe MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑?MtuT(ed b•ltseparate ,.❑ Widowed 0 Divorced 0 Unknown
<br />•
<br />11. FAT Rs NA14E (First, Middle, Last, Suffix)
<br />Alan Tully
<br />13 EVER:IN U.&:ARMED FORCES? Give dates of service if Yes.
<br />2.1`41$; No, or Unk.)
<br />8a. PLACE OF DEATH
<br />HOSPITAL al Inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />Sc. WY OR TOWN.
<br />Grand island
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />19e. APT. NO.
<br />94. ZIP CODE
<br />68803
<br />Facility
<br />T.
<br />9g.'INSIDE CfrilikirrS:;
<br />® YES ❑ NO
<br />40b. NAME OF:SPOUSE (First, , Middle, Last, Suffix) If wife, give maiden name:.
<br />Lloyd L Lor$orl
<br />14a. INFQRMANT-NAME:
<br />Lloyd.L.Larson
<br />42. MOTHER'S -NAME (First, Middle,
<br />Hazel Bradstreet
<br />Maiden Surname)
<br />14b RELATIONSHIP rt7 DEI
<br />Husband
<br />1814EPPD OF;D1SPOODION...
<br />❑Buried ❑ Donation
<br />® Cremation 0 Entombment •
<br />;❑ Renitiyal ;I❑ O.er::(Specity)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a 'FUNERAL HOME NAME AND MAILING ADDRESS (Street City or Town, State)
<br />Aofel'Funera1 Home. 1123 W. 2nd. Grand island. Nebraska
<br />18i;:'LICENSE NO.
<br />CITY' / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See Instructions and examples)
<br />ituPARYL Etter sir• Giwmevei is --diseases, inhales, or comphcatiens.hat directly caoabdthe death OD NQT enter:9nnihW events such as cardiac arrest,
<br />spgyfrate1y afaet\ or v@itt¢Cular fibrillation without showing the etiology. DO NOT ABBREIHA3E. Elder only ane cause an a line Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Respiratory Failure
<br />IMMEDIATE CAUSE(Finid.....
<br />disease or condition resulting
<br />8egwpidbibg bait .... • 7QnB:11.
<br />any leadingtethe eause8stad:��
<br />on I) a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Pancreatic Cancer Metastatic
<br />les. DATE (Ma Day
<br />September 25, 2019
<br />T.
<br />1Tb.Zfp Coda
<br />APPROXIMATE:0111 Wt1
<br />onset to death'
<br />1 Day
<br />DUE TO; OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(diseaas or iM.!nY tact hiltisfed:;:.
<br />airing in death) ;; ;::DUE TO, OR ASA CONSEQUENCE OF:
<br />"d)
<br />life events res
<br />LASY:
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS•
<br />❑ Na Pregnam.wnahe past veer
<br />0 Pregnant at time of death
<br />:❑ Na. pregnant, but pragiwahhi 42 days of death
<br />�-t Nat pr at}iteu. tnd p4egnaat+F* Gays to 1 year before
<br />death
<br />❑ ilrritnowe dtgrlaatvrWntde past year
<br />tfans contributing to the death but not resulting in the underlying cause given in PART 1.
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />❑ Accident ❑ Pending investigation
<br />❑ suicide ❑ C0uId net be detemdned
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Drtver/Operator
<br />0 Passenger
<br />❑ Pedesvian
<br />❑ Dther.(speciy)
<br />onset 10 death`
<br />ontiet lett death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONERy CONTACTED'?
<br />ID
<br />❑ YES
<br />21c. WAS AN AUTOPSY PERFORM
<br />❑YES IR NO
<br />21d. WERE AUTOPSY ANCMIGS AVAILABLE
<br />LE
<br />TO COMPLETE CAUSE OF DEATH?;::
<br />❑ YES< ❑ NO
<br />M."
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction $1
<br />2e«d INJURY AT WORK? 122e. DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />2$a DATE OF(?(wATH (Mo., Day, Yr.)
<br />Sterftber3.2019
<br />et (Spot)
<br />cirerrOWN
<br />b. b T'E SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />:Seoter,ber 4 019 05:50 PM
<br />9d. To !babes of my knowledge, death occuPed at the time, date and place
<br />and 4 to to the catise(s) stated. ISignahare and MIS
<br />isaaa J Ban MD
<br />STATE
<br />24a. DATE:. SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF
<br />TPI •
<br />21P CODE :.
<br />PRONOUNCED DEAD (Mo., Day,.Yr.) 24d. TIME PRONOUNCED DEAp
<br />Ye. w:, die base C. exanJ,at:on m'o,or irw ^ttr' tt.a' in nw .pMinn dant necwie, at
<br />the time, date and place and due to the a uas(a) staged: {signetas and Tide).
<br />25. DtD TOGACG ? iWE CONTRIBUTE TO THE DEAri? 26a. HAS ORGAN OR TISSUE DONATION BEEN 'CONSICERED?
<br />❑ YES O NO .. ❑ PROBABLY 0 UNKNOWN ❑ YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand island, Nebraska, 68803
<br />28a REGISTRARS SIGNATURE
<br />25b. WAS CONSENT (RAuTEO7
<br />Not Applicable N 26a le NO (D YES
<br />28b. DATE FILED BY REGISTRAR (Mo.,
<br />September 26, 2019
<br />00
<br />
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