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<br /> WHEN T�S COPY CAItlZIIES THE RA/SED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES • j �
<br /> SYSTEA�,IT CERT�S 7FE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE � '`
<br /> THE NEBRASKA HEALTHAND HUMAN SERVICES SYSTEM,wra�sransr��r��s
<br /> THE LEQAL DEPOS/TORY FOR VITAL RECORDS _ \
<br /> DATE I U f ���'�"jj":'-�._'
<br /> JUL��1�� 9 9 1 � 115 '���'�� - � :_ �
<br /> � �� _ �.
<br /> a������=
<br /> UNCOLN,NEBRASKA HEALTH AND�ll(SEltVICE$�y�=
<br /> STAIE OF NEBRASIU-DEPARTIv�Tf OF HEALTH AND HUMAN S�VTCFS�SU�RT
<br /> V1TAL STATISIICS = = - - -=_ - _ =_
<br /> CERTIFICATE OF DEATH = - ` _�
<br /> 1.OECEDENT-NAME PIRS7 MIOOLE UST . - 2 SEX � OP DEATH /MOnM DaY�Yeei/
<br /> Loretta Elizabeth Ericksen Female July 14, 1999
<br /> �.GTV AND STATE OF BIRTH /llirol'n U.SA..narn�covnby� Se.AGE-Ust BiNWay UNDER 1 VEAR UNDER i DAV 6.DATE OF BtRTH /AbnM.Day,YearJ
<br /> Aurora, Nebraska (�n'� p� Sb MOS. ' DAYS Sc.HpURS' MINS Tu7 V l^�, 1916
<br /> � �J 11 1
<br /> 7.$OCUL SECURTIV NUMBER � Ba.PLACE OF DEATH
<br /> � 505-92-9505 HOSPITAL: � InDa�ient OTHER � Nu�sing Home
<br /> � Bb.FACIUTV�Name /rynpfmsNWfpn,yn•suresNipnumON/ --�- � ER OutpetieM � .
<br /> ResiOence
<br /> , Wedgewood Care Center ❑ �oA ❑ ah,,,�,�.,
<br /> Bc.CI7V TOWN OH IOCATtON OF DEATH BA.INSIOE CITY LIMITS 8e.COVNTV OF DEATH
<br /> Grand Island �„ � ,� � Hall
<br /> Oa•REGtDENCi•S7ATE 9b.COUN7� 9e.CITV.TpWN"6R LOCATION 9d.STREET AND NUMBER /lnt/u0ligZip Code1 �9e.INSIDE CITV LIMITS
<br /> Nebraska Hall Grand Island #55 Kuester Lake �eg� No❑
<br /> �0.RACE-le.g..White.Black.Amsriean Intlian. t t.ANCESTRY le.g..IlaGan.MsKican.6srman.ekl t2.�MARRIED ❑WIDpWEO t 3.NAME OF SPOUSE /N wrle.giwm�iden n�mel
<br /> atc.11Spec�ry� r•�,, ISDeciNl
<br /> YYlllte American NEVEH DIVORCEO Arnold T. Ericksen
<br /> 14a.USUAL OCCUPATION IG�w kiMd Mpk dprr�dyinp mpa� 11D.KIND Of BUSINESS INDUSTRV 15.EDUCATION �Spenry oniy h�qhss�yrado compebA)
<br /> d workrng li/e.evsn ilro(ire01 Ebmentar�a�SsCpnCary 10-121 �Cdlqpe It.a or 5-�
<br /> Homemaker pomestic l� �
<br /> 16.FATHER-NAME FWST MIDDLE UST �7.MOTHER FIRST MIDDLE MAIDEN SURNAME
<br /> Harley Smith Mable Dean
<br /> 18.WAS DECEASE�EVER IN U.S.ARMED FORCES7 19a.INfORMANT-NAME
<br /> Ivas.��o.o��nt.� lu ves.qrve wu vitl tlaies ol aarvices� . �
<br /> No Arnold T. E�icksen
<br /> �90 INFORMhNT MAILING ADDHESS ISTREET OR R.F.D.NO..CITY OR TOWN STATE.21PI
<br /> 5 Kuester Lake, Grand Island, NE. 68801
<br /> 20.EMa MER-gGNaTURE 8 LICENSE NO. � 21a.METHpp pF pl$vpSITiON �210.OATE � - 21c CEMETERV OR CFEMATORV�NAME
<br /> � � � July 17, 1999 Aurora Cemete
<br /> Burial Rertwval
<br /> a.FUNERAL H -NAME 27tl CEMETERV OR CREMA70RV IOCATION C�T�OR TOWN STA?E
<br /> Apfel-Butler-Geddes ❑���^ ❑�a��^ Auro a, Nebraska
<br /> 22b.fUNERAL HOME ADDRESS (STAEET OR R.P.D.HO_qTY OH TqNN.SUTE,ZIP� ,
<br /> 1123 West Second, Grand Island, Nebraska 68801
<br /> 23. IMMEDIATE CAUSE �ENTER ONLV ONE CAUSE°ER LINE FOR ial.Ib�.AND�cll i Inlerval belween onsM ana aeair
<br /> PAFT ^ � �
<br /> / �
<br /> X � lal . �� L T�Gy/J C,��r� i �
<br /> DUE TO.OR AS A CONSEOUENCE OF i IMerval between onsei antl tleam
<br /> i
<br /> �b� I
<br /> I
<br /> DUF TQ,OF AS A CONSEWENCE OF' � Inte�va'C�tween o.^.cc:z-c 7=ar
<br /> _ -
<br /> Icl �
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<br /> OTHER SIGNIFICANT CONDR�ONS-ConAdions cawipu6nq tp the Eeath but nd relate0 PAqT III IF FEMALE.WAS THERE A 2a AU70PSV 25.WAS CASE REFERRED TO MEJICAL
<br /> PART PREGNANCY IN THE PAST 3 MONTMS?
<br /> tl E%AMINER OR CORONEi7°
<br /> (A9e5 10�SC� Ves No Ves No Ves NO
<br /> �a� 28b.DATE Of INJURV /MO..pay.Yr./ 28c.HpUR OF INJURY 26d.DESCRIBE HOW INJUAV URRED �
<br /> � AcciOent � U�tletermme0
<br /> M
<br /> � Su�aAe � apntl�ng 268.INJURV AT WORK 261 PUCE oF INJURV•qt ho"mq,larm.sueel.faClOry 26g.LOCA710N STREET OR R.F.D.NO. CI7V OR TOWN STaTE
<br /> O . . ❑ ❑ olfica[w�dinq,etc. /Sqcrry/ ,
<br /> + HpmiciGe inveSUgaGOn � Ve5 No
<br /> 27a.DATE OF DEA7H /AIO.Day.Yr/ 2Ba DA7E SIGNED /MO.Day Yr.l 280.71ME OP DEATH
<br /> ta �� � ��z
<br /> yyy M
<br /> �.�/', 27b.DATE SIGNED nuo..ay.v..i 27c TIME OF DEATH `�'g 28t.PRONOUNCED DEAD lMO_Day.Yt) 28d.PRONOUNCED OEAO /HOUrI
<br /> i� K
<br /> �i�
<br /> x�' �Ilo - II• d�S' M ���
<br /> °S 27E.To ihe best d my krqwb0gs.Gath xcuney a tiiM,ONe a n tl p l a e e uy Ws i p p w °�� p�.On tne pasis o1 sxaminatan anC�w investigaWn,in my oqNOn tleath occurred at M
<br /> cauaelsl subd. '1 /l /I // a p�i;�.da���e and Cue ro d»cause�sl stateC.
<br /> i -,�.ri ii. �
<br /> (S nature antl Titb t/��O«'(. /v� S nawro arW Title
<br /> 29.dD TOBACCO USE CONTRIBUT TO THE DEATH9 3p.a HAS ORC,AN OR TISSUE DONATION BEEN CONSIDERED? 3p.b WAS CONSENT GRANTEO?
<br /> � YES � Np �y� UNKNOWN � YES NO � VES NO
<br /> �re�
<br /> �t.NAME AND ADDRESS OF CERTIFIER�PHYSICUN,CORONEA'S PHYSICpN OR COUNTV ATTORNEVI lTyps a � 1
<br /> Daniel Cronk, M. . 908 N ster, Grand Island, Nebraska 68803
<br /> 32a REGISTRAR 32D.DATE FIIED 8V REGISTRAR /
<br /> • JUL 21"�
<br />
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