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<br />. STATE OF NEBRASKA .
<br />
<br />WHEN THIS COpy CA S THE RAISED SEAL OF THE NEBRASKA HEAL ND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOIJf)J)N"F1Le:-.",!!-!.H
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSTlCS$j!CTIQN;Wfj1J;/(fS::.
<br />
<br />:::;::~~:::::;TORY FOR VITAL RECORDS'~4wl' -~ti~:~_..
<br />
<br />;VV-'.. fFttANL:a=S; troOPER - -. ._
<br />
<br />OCT 242005 2 0 0 6 0 5 7 31 ASSISrANISTATE-REGlSfFiA!1.:.
<br />LINCOLN, NEBRASKA HEALTH itJ:lDilt{Mf!# SERVj~
<br />
<br />"",
<br />
<br />.. ~~:'::.~ft.,,;,;,.:-: :
<br />
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCEAND'SuProRT' "1""1 c: 0 ':)
<br />._"~ CERTIFJC.ATE OF DEATH.____ 05.~
<br />DECEDENT'S.NAME (First, Middle" Last, Sulflx) 2. SEX 3. DATE OF DEATH (Mo" Day, Y!J
<br />Karen Marle Powers Female Oct. 11, 200~
<br />
<br />'-..1
<br />~
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Boelus, Nebraska
<br />
<br />5a:"~GE.La" Birthday I 5D. UNDER 1 YEA~
<br />(Y's.) MOS. DAYS
<br />56
<br />
<br />50. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo" Day, Yr.)
<br />
<br />March 30, 1949
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />507-70-2386
<br />
<br />6a. PLACE OF DEATH
<br />tlO.S.f!JAJ.;
<br />
<br />IJ Inpatiant
<br />
<br />QIJ:!fB; IJ NU';ing Home/LTC (J Ho'plce Facilily
<br />
<br />FACILITY-NAME (If not Institution, give street and n\Jmber)
<br />
<br />iJ ER/Outpallerll
<br />
<br />~ Decadent's Home
<br />
<br />303 Alexandria
<br />
<br />Nebrasl'-.CL .
<br />9d. STREET AND NUMBER
<br />
<br />'--~t:GO~N~al~-
<br />
<br />IJ lXY\ IJ Other (Speelly)__ __
<br />16d. COUNTYlJFDEATH
<br />liall
<br />
<br />6e. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Cairo 68824
<br />
<br />303 ~~~..9:ndria
<br />lOa. MARITAL STATUS ATTIME OF DEATH ~ Married (J Neve, Married
<br />
<br />
<br />gl. ZIP CODE
<br />
<br />68824
<br />
<br />~'DE611:Y LIMITS
<br />:SJ YES IJ NO
<br />--"---".'..,.'-"..-..
<br />
<br />IJ Marriad, buts.peraled IJ Widowed IJ Divorced U Unknown
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<br />lOb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wile, give melden name.
<br />Leonard Powers
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<br />11. FATHER'S.NAME (First,
<br />
<br />Dale
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />
<br />Middle, Maiden Surname)
<br />
<br />Christensen
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<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />
<br />Lembur9:__
<br />14a. INFORMANT-NAME
<br />Leonard Powers
<br />
<br />E6aE~E-il~
<br />IJ Cremation IJ Enlombment 16d CEMETERY, CREMATORY OR OTHER LOCATION
<br />IJRemoval IJ Other (Speclly) Ebenezer Cemetery
<br />
<br />
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (SI,eel, Cliy o,Town, Slale)
<br />
<br />Richard
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<br />13. EVER IN U.S. ARMED FORCES? Give dates 01 service II yes.
<br />(Yes, no, 0' unk.) No
<br />
<br />15 METHOD OF DISPOSITION
<br />~Bu'ial U Donetlon
<br />
<br />
<br />16b. LICENSE NO.
<br />913
<br />
<br />CITY /TOWN
<br />Boelus,
<br />
<br />16c. DATE (Mo" Day, Yr. )
<br />OCt. 17, 2005
<br />STATE
<br />
<br />Nebraska
<br />
<br />112-st.
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<br />
<br />Zip Code
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<br />PART l. Enter the chain nf AVenltl--dlseases, InJuries. or complicatlons~-lhat directly caused the death. DO NOT enter terminal events suoh as cardiac arrast.
<br />rasplretory arrest, or venlficul., lib,illalion without showing the ellology. DO NOT ABBREVIATE. Enter only one cause on e line. Add additional lines II necessary.
<br />IMMEDIATE CAUSE:
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />Indeall1)
<br />
<br />la) LtJ
<br />DUE TO, OR AS A
<br />
<br />o.M-e1asiu-o/,' c ~~UPJMOuA ~
<br />NSEQUENCEOF: Cd/l~ t1 Cl~~ tJ-f tllll:t?CJ/MefH'UWl-
<br />
<br />I
<br />I
<br />
<br />I onset to death
<br />I
<br />
<br />..;..~~~.
<br />
<br />I onsello death
<br />I
<br />I
<br />--1_
<br />I onset to death
<br />I
<br />I
<br />__1
<br />I onsello death
<br />
<br />Sequentially IIsl condltions,lI (b)
<br />any,leadlngtolhecauselloted DUE TO, OR AS A CONSEQUENCE OF:
<br />on IIn...
<br />Enl...lhe UNDERLYING CAUSE
<br />(dloeoo. or Inlury that Initialed (c)
<br />theevenlsreeullingln deoth) DUE TO, OR AS A CONSEQUENCE OF:
<br />lJlST
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Condilions contribuling 10 Ihe death bul not ,esulling In the underlying cause given In PART I.
<br />
<br />fY;. CV b J J::, \j) b..Al1
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<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />IJ Y~S ;&, NO
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<br />20. IF FEMALE:
<br />1;l( NOI pregnanl within past year
<br />CJ Pregnant at lime of death
<br />IJ Nol p,egnanl, Dut pragnanl wllhln 42 deys 01 dealh
<br />IJ Nol pregnanl, bUI pregnant 43 days 10 1 yea' belore dealh
<br />o Unknown If pregnanl within the past year
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<br />21a. MANNER OF DEATH
<br />-;orNatural IJ Homicida
<br />
<br />IJ AccldentCJ Pending Investigallon
<br />
<br />IJ Suicide IJ Could nol be determinad
<br />
<br />21 b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />IJ Drlver/Operetor
<br />
<br />IJ Pass en gar
<br />
<br />IJ YES
<br />
<br />)(NO
<br />
<br />o Pedestrian
<br />IJ Other (Specily)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />IJ YES IJ NO
<br />
<br />IJ YES IJ NO
<br />
<br />
<br />m
<br />
<br />22.. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY..AI home, farm, .tr..I, faClo'y, offlca building, construction olta, .Ic. (Specify)
<br />
<br />2.d.INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITY/TOWN
<br />
<br />S1)lJE
<br />
<br />ZIP CODE
<br />
<br />:i!~
<br />ii'C3z
<br />"CcnQ:
<br />n~
<br />n.1l. II:( ~
<br />E."~Z
<br />8ffi 2: 0
<br />Ez::l
<br />~~8
<br />8 is
<br />
<br />26a. HAS ORGAN OR TISSUE D6NATlON BEEN CONSIDERED?
<br />
<br />24a. DATE SIGNED IMo" Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />m
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<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
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<br />24e. On the basIs of exa.mlnatlon and/or investigation, in my opinion death occurred at
<br />Ihe lime, dale end pIece and due to the causers) slated. (Signature end Title) "
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />DYES 1! NO IJ PROBABLY iJ UNKNOWN IJ YES)!(NO N,,-IA!,p!lc!,~I~ if 26a is NO IJ YES ~ NO
<br />---v.NAME,Ti1i~ AND ADDRESS OF CERTIFIER (PHYSiCIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Prinl)
<br />Richard Fruehling MD, 2116 W. Faidley #400~Grand Island NE 68802
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<br />28.. REGISTRAR'S SIGNATURE
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<br />
<br />28D. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />OCT 2 0 2005
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