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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TIjANIU1VMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE OR/~Fi~ii#fjl1~ FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL $tArt$'FICS:'-SEC11QN;OWHICH IS
<br />
<br />:::;::~~~~::~TORY FOR VITAL RECORDS. l/';-_~::'. '~tl.~~
<br />SEP 01 2006 . ~"l1""'$:dioPER
<br />JtsS,/ST4NT STATE jlm~TRAR
<br />fJEA[TH74~P!!tiM~-N SIfRVICES
<br />
<br />200609392
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />
<br />(First,
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT n C' 2'. g.IlI..: 2'. 3'
<br />'_. ._ CERTIFIC~TE OF DEATH u_\,J'~1 U
<br />2 SEX i 3. DATE OF DEATH (1.10, Day, Yr.)
<br />Female Augyst 17. 2006
<br />5c UNDER 1 ~A~ 6. DATE OF BIRTH (1.10, Day, Yr.)
<br />HOURS MINS
<br />July 7, 1919
<br />
<br />Middle,
<br />
<br />La.t,
<br />
<br />Sutllx)
<br />
<br />. .. :j:rene _...0..
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />@sk
<br />
<br />5a. AGE.Last Birthday 5b. UNDER 1 YEAR
<br />(Yr..) MOS. DAYS
<br />87
<br />
<br />st. Francis Medical Center
<br />
<br />laa.. PLACE OF DEATH
<br />
<br />
<br />
<br />j=m&
<br />
<br />M Inpatient
<br />
<br />QlliE8;
<br />
<br />o Nur.lng Home/LTC U Ho.plce Facility
<br />
<br />o ER/Dutpatiem
<br />
<br />o Decedent's Home
<br />
<br />Oro>.
<br />
<br />o Other (Speelty)
<br />
<br />o Never Married
<br />
<br />Island
<br />'~--g;:-- ....-
<br />ge':~~_LZI~~~~3
<br />
<br />lOb. NAME OF SPOUSE (Flr.I, Middle, Last, Sullix) If wll., glv. maldan nama.
<br />
<br />
<br />6d. COUNTY OF DEATH
<br />Hall
<br />
<br />68801
<br />
<br />. __._=-tC::~~_
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />::0 YES 0 NO
<br />
<br />Melvin D. Bahensky
<br />
<br />La.t, sullix)
<br />
<br />12. MOTHER'S.NAME (Flr.', Middle,
<br />Katherina
<br />
<br />Malden Surname)
<br />Hinrichs
<br />
<br />Dammann
<br />
<br />14a.INFORMANT.NAME
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />No Janis A. Gustafson
<br />o Donallon -[16~~~~~ER~IG~:ation -.' ... 1::'ENSEuNO.
<br />
<br />o Entombmenl 16d CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />
<br />o Olher (Specify)
<br />__ Central Nebraska Cremation Service
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreel, City or Town, State)
<br />
<br />J::l,:!uqhter
<br />16e. DATE (Mo., Day, Yr.)
<br />.ugust 18, 2006
<br />STATE
<br />
<br />Gibbon Nebraska
<br />17b. Zip Cod.
<br />
<br />P.O. Box 181
<br />
<br />St. Paul
<br />
<br />NE
<br />
<br />
<br />
<br />PART I. Enler the Ghllin. 9J~"dl.ea..., Injurle., Or compllcallon...lh.t dlreolly caused the dealh. DO NOT enter terminal.venls .uch as cardiac arrest,
<br />resplralory arrest, or venlricular tlbrlllallon wllhoul showing the ellolog~. DO NOT ABBREVIATE. Enler only one cau.. on a line. Add addlllonalllne. If necessary.
<br />
<br />IMMEDIATE CAUSE (Final
<br />dls..s. or condition resulllng
<br />In death)
<br />
<br />IMM~DIAT . AUSE:
<br />
<br />~(......
<br />(a) .' (,0"
<br />--..... n ...2....
<br />DUE TO, OR A A CONSEQUENCE OF;
<br />(b) /iL(c<l-t~fz ~4~(
<br />
<br />DUE TO, OR AS A CONSEOUEN OF:
<br />
<br />.(L~~~
<br />
<br />Yf~v)
<br />
<br />I on.ello death
<br />
<br />: ({fd&J
<br />
<br />ilequenll.lly list condition., if
<br />any,l@adlngtothecausellsled .
<br />on line G.
<br />Enter the UNDERLYING CAUSE
<br />(dt..... or Injury th.t Inltl.ted (c)
<br />th.eventsr.sulllngIn d..th) DUE TO~'AS A CONSEQUENCE OF:
<br />lAST
<br />
<br />onset to death
<br />
<br />onael to death
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS.Condlllon. conlrlbuling 10 the de.th bUI not r.sultlng In the underlying cau.e given in PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CS!;lIACTED?
<br />
<br />DYES ;tr NO
<br />
<br />20. VEMALE: 21 a. MAN~ OF DEATH-- 21 b. IF TRANSPORTATION INJURY
<br />i3'Not pregnant within past year Q1[.tural U Homicide 0 Drlv.r/Oper.lor
<br />
<br />o Pregnant at 11m. 01 death 0 Accid.nlO P.ndlng Inv.stigallon 0 P....ng.r
<br />
<br />o Not pr.gnant, bul pregnant wilhln 42 day. of death 0 Suicide 0 Could not be det.rmln.d 0 P.de.trlan 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Nol pregnant, but pregnant 43 day. 10 1 year before death 0 Olher (Sp.clfy) COMPLETE CAUSE OF DEATH?
<br />
<br />o Unknown if pr.gnant within the past y.ar 0 YES t...l NO
<br />
<br />22~:ATE OF INJURY (Mo , Day, Yr -; -... _' - '2_2b. D.ME OF INJ_U~:__ j 2~C..P~CE_ OF INJl!BY.AI he~e~ I.~m 'jr'l.et, 1/lOlory, oUlce..bulldlog, eonst,"ctlo~ ~ "i.r;SPealfYl
<br />
<br />
<br />22d.INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />21c. WAS AN AUTOPSY Pf:~RMED?
<br />o YES ~
<br />
<br />DYES 0 NO
<br />
<br />221. LOCATION OF INJURY. STRf:ET & NUMBER, APT. NO.
<br />
<br />CITY/TOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />,..~~
<br />.cd3 ~
<br />1i!W'"
<br />ll>P
<br />a.iE~::i
<br />E~tZ
<br />8ffizO
<br />~~::l
<br />J:l 0
<br />{l. u
<br />815
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo.. Day, Yr.) 24d. TIMf: PRONOUNCED DEAD
<br />m
<br />
<br />24a, On the basis of exa.mlnatlon and/or Investigation, in my opinion death occurred at
<br />thelim., dale and place .nd due to the caus.(s) stated. (Sign.tur. .nd Title) ,.
<br />
<br />AN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />o Yf:S ltl-11b
<br />d ~C\.O~t,3
<br />
<br />t<"\ . p.
<br />
<br />AUG 2 1 2006
<br />
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