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<br />>>` TE IJiFISSU.4 E
<br />STATE OF NEBRASKA
<br />:.mtva Nsr,>:+a236ot'I'I:L'P.Y,P1Ji°,
<br />'>aat7l),'CENtlssn
<br />THIS:; :: COPY CARRIES THE RAISED':.:SEAI L)F;; ;TH ;:STATE OF NEBRASKA,
<br />:CEERt1P`IES': ;II E DOCUMENT BELOW TO B€ : EA `TRU,E ::COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL..
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY fof irrAI ::RL�GUWAB
<br />5.
<br />3/16/2018
<br />NEBRASKA
<br />R
<br />ASiISTA( STATE RE
<br />DEPARTMENT HEALTH AN
<br />WHAM *ERVICES
<br />STATE OF NEBRASKA - DEPARI ENT Pf;HEALTRANtz HUMAN SERVICES
<br />CERTIFICATE'OF DEJ T
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Norman Paul Harrison
<br />4. C('.f f AW STYATE:CH:'IERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Sarsltrit,;'iJebraska
<br />7. SOCIAL SECURITY NUMBER •
<br />52.0-24-1237 .. .
<br />61t. AGs - t att.8irlhd .441. (mPER 1 YEAR
<br />8b.: FAC*UTY49,914 ; f il::o* lnadtution, give street and number)
<br />..AVA.MadiCafCenter-Grand.Island
<br />6c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island,:68803
<br />9a.. RISIbENCS- TA'( ::
<br />Nebraska >':>
<br />9b. COUNTY
<br />Hall
<br />9d. STREET AND NUMBER
<br />712 Haqae Avenue
<br />10a. MARITAL. STATU&:AT TIME OF DEATH ® Married 0 Never Married
<br />tli a�..
<br />Mt+d:bu etapasdl>d 0 Widowed 0 Divorced 0 Unknown ,:
<br />11.`FATHER'S-NAME :(first, Middle, Last, Suffix)
<br />Ernest Harrison
<br />13. s1 ER.IN RMEQ. FORCES? Give dates of service if Yes.
<br />09/19/1950-10/31/1971
<br />is 'ItAETHOD i t 'p4SFoSI:TtoN
<br />j'Biilal ''`0190riadon
<br />0 Cremation 0 Entombment
<br />C L Reixtova(: ' Q' r (Specify)
<br />'17at>FUNERAI; HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Aft` Faiths'FuftietaT Home, 2929 S. Locust Street, Grand Island: Nebraska
<br />Moe
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL E Inpatient
<br />• :511"3'E %Outpatient
<br />90,;CITY tali TOWN
<br />:and tstand
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />Nove17 ie6 < 192
<br />OTHER ® Nursing Homo/LTC
<br />❑ Decedent. Horns
<br />Q other (Specify) •
<br />Sd. COUNTY OF DEATH
<br />Hall
<br />De. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />lob.NAME;OF.SPOUSE (Elsa,.. Middle, Last, Suffix) If wife, give maiden forme
<br />Elizabeth `:Arl;ri.;Galrat#er
<br />12, MOTHER'S -NAME (First, Middle,
<br />Helen Inez Dutton
<br />14s. INFORMANT-NA..ME
<br />Elizabethn H
<br />An.. atftscln .
<br />16a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION .
<br />Westlawn Cemetery
<br />lab. LICENSE NO.
<br />1071
<br />CITY I TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See: instructionsand examples)
<br />'fi,:PARTI Enterine chain in' mints -,diseases, injuries, or complications -that directly caused the death: DO apt. .chartfira:i7ml events such as cardiac arrest,
<br />impiretory:arrest, ol::Penkkiinuler fibrillation without showing the etiology. DO NOT Akmlla/iATE>,:Sirlar yitig oils rauiNAil a?Ik:Is. Add additional limes it necessary,
<br />IMMEDIATE CAUSE:
<br />**MEDIATE CAUSE I a) Respiratory Arrest
<br />`disease or condition resulting
<br />:.in
<br />• seguintlgINEbt:corm nis.. f >:
<br />afY<;fterllnq:'to Ktaees;fle:trid
<br />Enter the UNDERLYING CAUSE
<br />ctdie.+ie►:es irUufytftat:ilft*tsd
<br />:'Ihi::eusMS:seaatiilpin SUM)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Chronic Obstructive Pulmonary Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART li. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1,
<br />CtiF,Oarcinoma,.Of;The Prostate,HTN,AFIB, Pulmonary HTN
<br />Not.. gliirkwnlifripsstysar
<br />- Q Pregnant at time or death
<br />Q:: Mgt, pregnant, hut, pregnent within 42 days of death
<br />Not prsgrNltrpufi'tredtta!{t et day. to 1 year before death
<br />UPktfptwn,if ptignam within thepast year
<br />22*.• DATE OF INJURY (Mo., Day, Yr.)
<br />32d 1 tJURY ATWOR1.? :.
<br />21a. MANNER OF DEATH..:::. .:
<br />Natural E Hemicid a
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide Q could not tit deferral eat)
<br />22b. TIME OF INJURY
<br />21C IP TRANSPORTATION INJURY
<br />CI Driver/Operator
<br />❑ Passenger
<br />Pedestrian
<br />"liar 6
<br />( pecihi
<br />ur
<br />14b. RELAi19t110.! R;F !IPA
<br />Spouse':
<br />too, DATE (Mo, Day,
<br />Ma, ch 18,1;201.8
<br />STATE
<br />APPROXIMATE
<br />onsets death
<br />death
<br />Minutes
<br />--r wterff.N :•
<br />dl
<br />onset to death
<br />19, WASH
<br />OR CORER;
<br />Q YEs<>
<br />21c. WAS AN AUTOPS :P:i
<br />Q YES
<br />21d WERE RUMMY' ;.FRARROil,AVIRI.A
<br />TO coMI ,ETE CAUSEOF Seitz..
<br />22c. PLACE OF INJURY -At home, farm, street, f.ctory, office building, construction
<br />22e, DESCRIBE HOW INJURY OCCURRED
<br />22f, LOCATION OF INJURY STREET.& NUMBER, APT.NO.
<br />23a.>:DATE ;OFDEATH (Mo., Day, Yr.)
<br />'Mardt11':<2018
<br />CITY/TOWN
<br />23b DA.7010.ED (Mo., Day, Yr,) 23c. TIME OF DEATH
<br />Z March 12'r 2018 06:28 PM
<br />G 3d. To the beet of my knowledge, death occurred et the time, date and place $ r� 2M. On the basis of examine** and/or investigation. in*
<br />o and due to the cause(s) stated. (Signature and Title) o b the time, data and place and due to the caua(s)salefat.I
<br />ShavOn $$: 'i awrence, MD <e;:t; ,: I «:
<br />21i O1D 1094O 'iUSE.:OONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISS.UEDoisis N.aREN :ONS(DERED?
<br />'YES ..Q NO' Q PROBABLY 0 UNKNOWN 0 YES ""`tZI NO'' ` .
<br />27. NAME, TITLE AND Aooke S OF CERTIFIER (Type or Print
<br />Shawn $::Law.rence, MD, 223 South E St, Broken Bow, Nebraska, 68822
<br />2
<br />STATE
<br />4s I71A 24b. TIME OF DEATH :::.'
<br />::;PRONOUNCED DEAD (Mo., Day, Yr.) 24d, TIME .PR !lips
<br />YE SIGNED (Mo., Day, Yr.)
<br />iS:RAR
<br />A- acIptot-
<br />Not Applicable If 26l, le N.O
<br />28b. DATE FILED BY REGIST
<br />March12, 2018
<br />
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