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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND~'1.MM~~f:/:;'~~
<br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL}!F6Q-AA~ -"'=0 S
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlf:rlfS:S~~N[~K:fJ/
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. .~....'._:.'-.~...-_Z~_'. -~-- .~. :;0 ~.;~. ..'.-~";...::~~~........-_,-.~t.:
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<br />DATE OF ISSUANCE '.'Pf:"FJITANLE'h&~OPPEl!
<br />AUG 3 0 2006 ASSlStANT STATEREG/~7!l~.fl
<br />LINCOLN, NEBRASKA 200 7 0 0 4 6 2 HEALfJ!~_'ilt/1~i!rf~'ffs
<br />.-,- . ,~,,-=. .=-:='
<br />.'~ ".. ", '..'~' :: ~--=-.""
<br />- .~', ::'~.2.._~ ,~,
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<br />_..__ STATE OF N~BRASKA- DEPAR~~~~I~~~f;~N~~U~~~s.;~VIC!!S FI~ANCE AND SUPPORT n~2:..9.J.41i
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<br />1. DECEDENT'S'NAME (FirS!, Middle, Last, Suflix) 2. SEX 3. DATE OF DEATH (Mo., Da1' Yrl
<br />Harlan Dean Sorensen Male August 23, L006
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<br />4. CITY AND STATE ~R TERRITORY, OR FOREIGN COUNTRY OF BIRTls. AGE'L~~I Blfthd~1:Yb UNDER 1 Y~AR 5c. UNDER 1 DA~ 6. DATE OF 81RTH (Mo,,'~~;:v;:)
<br />(Yra I MO~YS H..'O.~.RS MINS.
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<br />Dannevirke, Nebraska 73 ~ _~ . L J1!~~L 193)_
<br />7 SOCIAL SECURITY NUM~ER ra PLACE OF DEATH
<br />- -- __~07-34-521.~ _ _ !:l.Q.8illAl.. Olnp.lI.nl QlliEB: 0 NuralngHomefLTC OHosplcoFocllity
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<br />"" ;~~"~:::~" ;'~:~;";~:~ ",," '"" ""'=- 0 "ro.,,",", Ii ~,"",,~,
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<br />o !Xl', OOther(Specity)_..__
<br />6c CITY OR TOWN OF DEATH (lnclud.ZlpCo~- - -- - -- -18d COUNTY OF DEATH '-'-'-
<br />_---.9-rand Isla~ _ .~ Hall
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<br />9: R;:~:::::._ __ ~::~TY -~-- - LliY~::~~ Island --------
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<br />9d STREET AND NUMBER - ~-APT NOJ9U!PCODE --J9g INsIDECrrYLIMITS"
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<br />908 South Stubr Ro~._._ -__J_~_ 6880~___L_~_~~_~NO
<br />lOa MARITAL STATUS AT TIME OF DEATH ~.r"od 0 N.vor M.rried' F NAME OF SPOUSE (Flrsl. Middle, Last, SuffiX) If wife, give m.lden neme
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<br />OMarned,bulsepar.led l.lWldowod o Divorced o Unknown --1__ Shirley Holmes
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<br />11. FATHER'S~NAME - (F~ -- M~- Last, - ----s;;;;;xj--F2 MOTHER'S-NAME (First, -- Middle, - - M.'don Surneme)
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<br />_Qswal<!__.__ Sorensen ~ Elsie Rasmussen
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<br />13. EVER IN U.S. ARMED FORCES? Give deles of service if yes. 14a INFORMANT.NAWbrensen ~4b RELATIONSHIP TO DECEDENT
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<br />- (Yes.no,orunkf~/25/52-12/4/53 Shir1eY'Sl?YeR~5R =-=---=_ ~ife--=-=--
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<br />15. METHOD OF DISPOSITION ER-SIGNATURE "'I =C6b LICENSE NO 16c. DATE (Mo, Day, Yr.)
<br />~Burial o Donallon R... oU.-<..~ 1143
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<br />OCremellon 0 Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY fTOWN STATE
<br />o Removal U Othar (Spoclfy)
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<br />Westlawn Memorial Park Cemetery, Grand Island, NEbraska
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<br />1"7~. FUNERAL HOM'E'NAME AND-"MAILING'ADDRESS ~ty orToW~, State)--~'-'-' '-~_. "~.~~'''-'-'-
<br />Livingston-Sondermann funeral Home, 601 No. Webb Rd., Grand Island NE
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<br />PART L Enter the ~~,!11.~,,'dlseases, InJurlesl or compllcalions--thal direcfly caused the death, DO NOT enter lerminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etlology. DO NOT ABBREVIATE. Enter only one caUSe on a line. Add addlUonallinBs if necessary,
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<br />APPROXIMATE INTERVAL
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<br />IMMEDIAT~ CAUSE (Final
<br />di.ee.e Or condition ..oulllng
<br />In dealh)
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<br />I
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<br />I ~elIO death
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<br />-- _i_Jj_tBh-_
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<br />I onset to death
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<br />.- .----.- --..--. .-.~-----'--- ---..-.----
<br />I onset 10 death
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<br />... -. ----. '-,_.. ------L- .__ ._
<br />j onsel1o death
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<br />IMMEDIATE CAUSE:
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<br />(a) P \,,~ ~~r 1---' L",-. V'~. Co~. CJ2(
<br />~",_I~__~,_-._,_., "_.._,_,,'_
<br />DUE TO, OR AS A CONSEQUENCE OF:
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<br />Sequentially liot condition., If (b)
<br />eny, leedlng 10 Ihe ceuae IIsled -----pjJEro, OR AS A CONSEQUENCE OF';
<br />on line a.
<br />~nler IIle UNDERLYING CAUSE
<br />(dl.ease or Injury Ihsllnlti.led (c)
<br />Ihe evenl. r..ulllng In dealh)
<br />LAOr
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<br />-'-'---_._,~.~..-
<br />DUE TO, OR AS A CONSEOUENCE OF:
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<br />~ I
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<br />- ;o;;;m,.","" ;,~""',".c~om""<,",,;,", co","".""" ro '"' "''''' ~""' ,,,,",, '".., ""~'"" ..." .~" '" "'"" . ~WM '''''~ ~~'"'"
<br />OR CORONER CONTACTED?
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<br />- ____ ~___ _O~~__
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<br />20. IF FEMALE: ~. M~NER OF DEATH 21 b. IF TRANSPORTATION INJURY ~. WAS AN AUTOPSY PERFORMED?
<br />Nalurel 0 Homicide LJ DrlvsrfOperator
<br />o Nol prognant within past year 0 YES '<i' NO
<br />o Pregnant allime of d.ath 0 AccidentO Pending Invostigalion 0 P....nger " ~
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<br />o Nol pregnant, but pregnanl wllhin 42 days of death 0 Suicide 0 Could nol be determined 0 Pedestrian
<br />o Not pregnant, but pregnant 43 days to 1 ye.r before death 0 Other (Specify)
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<br />W Unknown II pregnant wllhln the past year _"',__._,.~
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<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE TO
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<br />COMPLETE CAUSE OF DEATH?
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<br />DYES 0 NO
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<br />. :J?A_I),ATE OF INJURY .IMo D~v Yr.1 -- - ~ I!MEJ2E.LNJILR~1 AGo QfJ!:jJI,!Bl.AI home, ';U!', Weet ,.;tnry O"'':.~hllll~IM c~n,t",oflon ~,I. ~,c mnec~fvl ~-
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<br />22d. fNJURY AT WORK? 220. DESCRIBE HOW INJURY OCCURRED
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<br />DYES 0 NO
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<br />_.'~._--~..._-._- - --""-'.-
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<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
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<br />CITYITOWN
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<br />STATE
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<br />ZIP CODE
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<br />..--- _.,---'--,----
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<br />Am
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<br />z>-
<br />!'SW
<br />'Illiil!
<br />ij>-P
<br />1iif5::i
<br />P/:~
<br />uffiz
<br />11155
<br />~a:U
<br />o~
<br />U 0
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<br />24.. DATE SIGNED (Mo., Dey, Yr.)
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<br />24b. TIME OF DEATH
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<br />.~"'--"--'-- -. --.
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<br />24C. PRONOUNCED DEAD (Mo.. D.y, Yr.) 24d. TIME PRONOUNCED DEAD
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<br />24e. On the basis of examination and/of invesllgalion, in my opinion dealh occ\Jrred al
<br />the lime. dalo and piece and due to Ih. causers) slated. (Signalure and Tille) .,.
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<br />~. DID TOBACCO USE CONTRIBUTETOTHE DEATH? 2~ HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
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<br />__ 0 YES"_~..._.O PRO~~B~UNKNOW~ _ O.~ __~9"'0 ___
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PIIYSICIAN, CORONER'S PHYSICIAN OR COUNTY ~Y) (Type Or Plln!)
<br />Dr. Donald Wirth, 2116 W. Faidley Avenue, Grand Island,
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<br />~. WAS CONSENT GRANTED?
<br />.. Not Appllceble i126~is NO UYES LJ ~~
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<br />NE 68803
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<br />28a. REGISTRAR'S SIGNATURE
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<br />AUG 2 8 2006
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<br />28b. flATE FILED BY REGISTRAR (Mo" Dey, Yr.)
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