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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEA&l'!t"A SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL S7" THE LEGAL DEPOSITORY FOR. VITAL RECORDS. DATE OF ISSUANCE JUN 1 9 2907 LINCOLN, NEBRASKA DECEDENT • NAME Harley he M AND STATE OF aPTH norw U5 A .aw•mussy West Point, Nebraska �SCt�IA�LL SSEQEC�UURT��IT pNNUMBER '50548-0908 202406017 STATE OF NEBRASKA. DEPAN/IMM TOF HEALTH VITASTATISTICS mama CERTIFICATE OF DEATH FIRST MIDDLE LAST 2 SEX 3. DATE OF DEATH IMAR M Day Cana Dean Rozendal Male ,November 09, 2004 Na AGE • LaI1 SAMaY UNDER t DAY 0 DASE OF BIRTH IM011/i. Div VAW, 1Y,5, 55 Sb MOS ' oAvs Sc ROUES A MINE I• May 08, 1949 Ss FACILITY• Name re of rmaxim 9Y, woo ana +wn10NJ St. Francis Medical Canter I c ,CITY TORN OR LOCATION OF DEATH Tad NSIDE CITY LIMIfs UNDER T YEAR 96 RESIDENCE• STATE i90 COUNTY T9c CITY TOWN OR LOCATION Nebraska Mall 'Grand Island 10 • ?.L • ieq. Wnae Blaa Amevcln Wan Tt ANCESTRY'eq IMM O MWICII' Oemwl. elcl T2ID WAVED L i NI 1 l u� � nE ?as USUAL OCCUPATION 'Ovebl40a AxwAtII9nota INDUSTRY d le ,L Me. even a roma1 Auto Technician TA FATHER •NAME R. Nab KIND O: BUSINESS V►utomotive FNNST MIDDLE LAST Vernon Rozendal tT MOTHER Irene Es PLACE Of DEATH tgSOR/1 loosoo M ER Ouf00Mra 0 DOA OTHER 240009Roma QRaiOanCa • 0 Oil ..SMS`•'v. 90 STREET AND NPJMBEA aximor 9?o Code) 22 E. Bismark Ave., 68801 WIDOWED 13 NAME OF SPOUSE t435 [� DIYQRCED Florence E. (, Is EOLIC IQN IScscav coy twlaM �✓um taMONaA 9e MSdECITvL.PMMTS to WAS DECEASED EVER IN U S ARMED FORCES'' 06/27/1969— i t9A INFORMANT • NAME YCI na aIJIIMI _IX yes war albOWsaMMMI Florence E. Rd1:8nda1 Yes (Viet Nam War 06/26/1975 !! T 90 INFORMANT MAKING ADDRESS 'STREET OAR F 0 NO. CITY OR TOWN STATE MI 822 E Bismark Ave., Grand Island, Nebraska 68801 EMBALMER - SIGNATURE a LC 1254 UNENAL Kleine F 226 FUNERAL'HOME ADDRESS ISTNIlT OR R.F 0 NO CITY OR TOWN STATE. ZIPI 3213 W North Front St Grand Island, NE, 68803 23 IMMEDIATE CAUSE 'ENTER ONLY ONE CAUSE PER LINE POW ial 0L AND ICI) PART f/ 11 I ;a; VCJfro.YT rCjits1+N, k' Ff,r►..� DUE �/MMTO. OR AS A CONSEQUENCE OF IP' ArI7 a ITN4,664/{,.T ( AdaPMA LrMMA•w if Fla kspahr. '.:Msr'�..1_ +_ -w .%lf�' 9t�r 'r DUE TO OR AS A CONSEQUENCE OP 210 DATE 11/13/2004 FIRST 210 CE WEERY ORCREMA Gibbon, Nebraska ENmeMRy 01 Secona v '0 III WOOLS (NMI) YNt] N tea"""! Ctrase n,ta WR %WOEN %MOM Liibbe ` 2tC CRIMPY OR CREW" ORv NAAR Central Nebraska Cremation Servi+ taW LOWTIOMr GTv :� TOWN 2ta METHOD OF DISPOSTiON BunM ❑ Removal Camroe ❑ DonaaP^ OTHER SIGNIFICANT CONDITIONS • CaIMMns COngRIMIQIo the EMER TIP not TeaNa PART 1 PART aI IF FEMALE WAS THERE A 12a AUTOPSY PREGNANCY W THE PAST 3 MONTHS/ 1 Ages to sal via ❑ Na ❑ YN 26a i 26b DATE OF INJURY IMP Day Yrl tat NOW OF INJURY ; 2NE DESCRIBE HOW INJURY OCCURRED ii Accaem 0 Unaearm"ne0 ( M II i 0 SuvMe 0 Penamq 126e INJURY AT WOIW 12M pk►sE0F P4R Y 1:06r isvns 'a* %dory Ma LOCATION STREET ORRF 0 7 Nam,CMe InWstgMMI Yes ❑ N0 a ; o q �FM1'1 2T6 DATE OF DEATH MnIDay Y, ) 97t.E }. 2Tb DAr SIGNED +Mo Day vt; '2Tc TINIE OF r 29C PRONOUNCED DEAD Mn Day. v.) !adPfIQNOVNCED OEAC My /id/ey �4Yc M a 2ra Tnmebearee imowaaOM asMtoecu,•eeMMRMIMMI6 W4leisc.allaeuebw 2MM tneMae aaeaww;awnaMah'AMIMBMOn•arty mono. MAP acctrl,as / CIu4e0, SOW , IP* Nne. OMf ano PIMN aM alle M M TAYeatsl sMOM ,Sgmoi•anOTMI► C 6� /L1 /fr/•n 'SMII lul9an0Ta191► 21 DID TOBACCO USE CONY - • DEATH" A", e HAS ORGAN OW TISSUE DONATION BEEN OONBgERED' 39E WASCONBENTQ GRANTED' (�(}} ❑ YES � NG ❑ UNKNOWN ❑ YES , NT YEs Rt NC= 1 TT1 31 NAME ANO *OGRESS OF CERTIFIER .PHYSICIAN CORONER S Horsier* ^w^f'MJMTY IGIORNEY. ?.gear P Y Jeffrey K. King, M.D., 72' N Custer Aye., Grand Island, NE 68803 26a DATE SIGNED MD Day Y, WWIva%tawlwl °MaOOM 900 25 WAS CASE mimeo Towner& EXAMINER OR comma - vas • C1t Y OR TOPA STATE "Bo REGISTRAR 12M TINE OF OEAAI 32e DATE MLED BY IMOMmo o A IN Car - NOV 8• 2004