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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BEA TRUE COPYOF THE ORIGINAL RECORD 01V FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICSJSFEG�'L�_V,._4MCH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />JAN 2 5 2006 _: TANLEY$& OOOPER
<br />LINCOLN, NEBRASKA 200601700
<br />ASSISTANT HUMIAN'SE�VItES_'
<br />MEALTfI_AIVD HUII9AN'SER1!lCES
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AN➢DSSULP T
<br />_ CERTIFICATE OF DEATH H _ `= 6 2 015 3
<br />1. DECEDENT'S•NAME (First, _ Middle, Last, Suffix) _ 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Raymond Earnest Larson JR Mate January 7, 2006
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH I 5a. ZE6Last Birthday 5b. UNDER 1 YEAR 5c. UNDER
<br />BIRTH (Mo., Day, Yr.)
<br />(Yrs.) MDS. DAYS 1 DAY 6. DATE OF BIHOURS MINS.
<br />North Platte, Nebraska 1 68 1 1 1 1 1 October 1, 1937
<br />7, SOCIAL SECURITY NUMBER Bo. PLACE OF DEATH
<br />506 --42 -4291 HOSPITAL; ❑ Inpatient QThF 10 Nursing Home /LTC ❑HosplceFacility
<br />Bb. FACILITY -NAME (If not Inagtutlon, give street and number) ❑ ER /Outpatient ❑ Decadent'sHome
<br />Western Hall County Good Samaritan ❑ OtlA ❑Other(Specily)
<br />_ Center _
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) Bd. COUNTY OF DEATH
<br />Wood River, 68883 Hall
<br />9-.R IDENCE-STATE 9b. COUNTY So. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />9d. STREETAND NUMBER
<br />9e, APT. NO
<br />9f, ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />9g. INSIDE CITY LIMITS
<br />1014 E. Nebraska AV
<br />I onset Id death
<br />68801
<br />/e/4 / w' Y. tzh(ce4x�
<br />X YES Q NO
<br />10a. MARITAL STATUS AT TIME OF DEATH g[Married U Never Married
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wile, give maiden name, w �-
<br />❑ Married, but separated ❑ Widowed ❑ Divorned U Unknown
<br />Donna Friesen
<br />24c.PRONOUNCEDDEAD(Mo..Day.Yr.)
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Raymond E. Larson SR
<br />Bessie
<br />Rader
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If yes.
<br />14a.INFORMANT-NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />(Yes, no, orunk.) NO
<br />Donna Larson
<br />Wife
<br />15. METHOD OF DISPOSITION M&E LMER-SIGNATURE �" 7 NSE N0.
<br />16b,_1I E�2
<br />160. DATE (Mo., Day, Yr. )
<br />(
<br />NBurial El Donation �� mm
<br />Jan 11, 2006
<br />W
<br />❑Cremation El Entombment 18d .CE6 ETERV,CgEMATORYOR.OTHERLOC TIOA N CITY /TOWN
<br />STATE
<br />QRemoval ❑ other (specify) Grand Island City Cemetery Grand Island
<br />NE
<br />17a. FUNERAL HOME NAME AND MAILING ADORES& (Street, City or Town, State)
<br />17b. Zip Code
<br />Curran Funeral Chapel 3005 South Locust Street , Grand Island, NE
<br />68801
<br />' PART I. Enter the chain of events -- diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />I
<br />respiratory arrest, orventricular fibrlllallon Without showing the etiology. DO NOT ABBREVIATE. Enteronlyone cause on a Ilne.Add additional lines If necessary.
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b, TIME OF DEATH
<br />IMMEDIATE CAUSE:
<br />I onset Id death
<br />IMMEDIATE CAUSE (Final
<br />/e/4 / w' Y. tzh(ce4x�
<br />w' -1
<br />disease or condition resulting
<br />-(e). ,.... _
<br />DUE TO, OR AS A CONSEQUENCE OF;
<br />_.L.._..a
<br />I onset to death
<br />Indeath)
<br />24c.PRONOUNCEDDEAD(Mo..Day.Yr.)
<br />24d,TIMEPRONOUNCEDDEAD
<br />Sequentially list conditions, If
<br />(b) © 00
<br />m
<br />any, leading to the cause listed
<br />-
<br />DUE T0, OR A5 A CONSEQUENCE OF;
<br />I onset to death
<br />on line a.
<br />�V. To the I of my knowle , dealh occurred at the tlme, date and place
<br />and ue to he ceuse(s sl ted. (51 and Tlllo)
<br />w
<br />.$ p 2
<br />Enterthe UNDERLYING CAUSE
<br />I
<br />(disease or Injury that Initiated (a)
<br />the events resulting In death) , DUE T
<br />LAST O,ORASA CONSEQUENCE OF-
<br />(d)
<br />18. PART IL OTHER ^.._ - ......__.. ____.,.....
<br />SIGNIFICANT CONDITIONS- Condillons contributing to the death but not resulting In the underlying cause glven in PART I.
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />Q Not pregnant; but pregnant 43 days to 1 year before death
<br />❑ Unknown If pregnant within the past year.-
<br />21s. MANNER OF DEATH. 21b tF TRANSPORTATION
<br />][Natural ❑ Homicide Q Driver /Operator
<br />❑ Accident❑ Pending Investigation ❑ Passenger
<br />❑ Pedestrian
<br />I onset to death
<br />I
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES XNO
<br />❑Suicide Q Could not be determined 21d . WERE AUTOPSY FINDINGS AVAILABLE TO
<br />22e. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY
<br />m
<br />22d.INJURYAT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />(] YES ❑ NO
<br />❑ Other (Specify) COMPLETE CAUSE OF DEATH?
<br />❑ YES U NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction alto, etc. (Specify)
<br />22L LOCATION OF INJURY - STREET &NUMBER. APL NO. CRYITOWN
<br />STATE ZIPCODE
<br />F C - " ` tl U
<br />U a
<br />DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERE07 266. WAS CONSENT GRANTED?
<br />YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES 1R NO Nal Applicable if 28a is NO C1 YES J� NO
<br />2.NA E,TITLEANOADDRESSOFCERTIFIER ( PHYSICIAN, CORCNER 'SPHYSICIANORCOUNTYATTORNEY) (Type or Print)
<br />David R. Colan LID 729 N. Custer AV, Grand Island, NE 68803
<br />28a. REGISTRAR'SSIONATURE �*� A 1 . ;tm, I 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JAN 13 2006
<br />13a, DATE OF DEATH (Mo., Day, Yr,)
<br />z r
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b, TIME OF DEATH
<br />yr
<br />7796.DATESIGNED(Mc.,��Dyyay,Yr.)
<br />2,p.TIMEOFDEATHnJ%DOh
<br />YI
<br />�
<br />6�
<br />24c.PRONOUNCEDDEAD(Mo..Day.Yr.)
<br />24d,TIMEPRONOUNCEDDEAD
<br />0
<br />S
<br />m
<br />Z
<br />$ 0
<br />m
<br />�V. To the I of my knowle , dealh occurred at the tlme, date and place
<br />and ue to he ceuse(s sl ted. (51 and Tlllo)
<br />w
<br />.$ p 2
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred et
<br />tha time, date and place and due to the cause(s) staled. (Signature and Title ) •
<br />F C - " ` tl U
<br />U a
<br />DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERE07 266. WAS CONSENT GRANTED?
<br />YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES 1R NO Nal Applicable if 28a is NO C1 YES J� NO
<br />2.NA E,TITLEANOADDRESSOFCERTIFIER ( PHYSICIAN, CORCNER 'SPHYSICIANORCOUNTYATTORNEY) (Type or Print)
<br />David R. Colan LID 729 N. Custer AV, Grand Island, NE 68803
<br />28a. REGISTRAR'SSIONATURE �*� A 1 . ;tm, I 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JAN 13 2006
<br />
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