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<br />200702837 <br /> <br />1. Ol!,MO~NT'S-HAME <br /> <br />(Fi",. <br /> <br />STATE OF Nlj:BAASKA - OEP~ENT,Of HEALTl-t ANO HUMANSERVI.GES FINANCE ANO SUPPOR322925 <br />CERTIFICATE OF DEATH" <br />i 2. S~X 3. DATE OF DUTH (YO.. D_y. Yr.) <br />Female Jul 16 2006 <br /> <br />Middlt. <br /> <br />Ln'. <br /> <br />$ullll) <br /> <br /> <br />Karen <br /> <br />Darlene <br /> <br />Markussen <br />'I h. AGE.L..181r1Mly I Sb. UHOERl VEA~ : <br />(Yr") 66 I MO$. i DAYS I <br /> <br />j ".P~E OF DEATH <br />tIQifJIAl.; <br /> <br />Se UNDeR' DAY <br />HOURS MINS. <br /> <br />f. DATE OF SIRTH (II... D_y. Vr.1 <br /> <br />I. CITY AND STATE OR T~RRITORY. OR FOREIGN COUNTRV OF SIRTH <br /> <br />November 20, 1939 <br /> <br />II Inp_li.nl <br /> <br />QII:iB <br /> <br />:;;I Nu...ng HoIMI\.TC ::I Hoeplea ''''''ily <br /> <br />(II nol in_ll1ull.n. Q'v_ 1Ir..t lnd numb") <br /> <br />o EAlOulp_lI.nl <br /> <br />a Doee<jon'" Homo <br /> <br />Methodist Hospital <br /> <br />aD <br /> <br />a OIIler ($peeily) <br /> <br />8<:. CITY OR. TOWN OF DUTH lInelud. ZIp COdI) <br /> <br />Omaha: 68114 <br />91. RESIDENCE-STATE lb. COUNTY <br /> <br />Nebraska Hall <br />1ld. STREET ANO NUMIlER <br /> <br />403 S. Harrison <br />10.. MARITAL STATUS AT TIME OF Oi,lTH QtM.",.d 0 101_' M."'.d <br /> <br />:;;I ~"iod. bul.IPa,otea CJ wlao...a I;] DiYOreed 0 Unkn...n <br /> <br />8d. COUNTY OF DeATH <br />Douglas <br /> <br />lie. CITY OR TOWN <br />Grand Island <br />i 9.. APT. NO <br />! <br /> <br />19f.ZIP CODE <br />68803 <br /> <br />i <br /> <br />9g. INSIDE CITY LIMITS. I <br />Jl VES :l NO ! <br />. --l <br />I <br /> <br />lOb. NAME OF SPOUSE (Flro.. MI<I<lI.. Lao'. SuHi.) lI..il.. give mOla.n namo. <br /> <br />John Keith Markussen <br /> <br />". FATHER'S-NAME (Fi"l. <br /> <br />Mlddl,. <br /> <br />Latl. <br /> <br />Sulll>) <br /> <br />12. MOTHER'S.NAME (Fi'e1. <br /> <br />MiddlO. <br /> <br />Ma,don Su,namol <br />Schwarz <br /> <br />-..,.-.-.. <br /> <br />Ervin Kamrath <br />'3. EVER IN u.s. ARMED FORCES? GI.o dol...t """eolf Y'" : "a.INFORMANT.NAME <br />(Vol.no.olunk.) No I John Markussen <br />l$..METHODOFDISPOSITION :\' '81EM~T.~RE ~d. <br />~8u"01 a Oenollon ~ V\ <br />::J Cremation CJEntombmenl i 10<1. CEMETERY. CREMATORY D THER LOCATION <br />I <br />o Romovol CJOlhar(SplCl'fy) Crown Hill Cemetery <br /> <br />Anna <br /> <br />CITY I T.oWN <br /> <br />14b. RELATIONSHIP TO DECEDENT <br />S QUSe <br />life. DATE (MQ.. Day. VI. ) <br />.. July 20 , 2006 <br />STATE <br /> <br />116~. LICENSE NO. <br />! 1135 <br /> <br />Madison <br /> <br />Nebraska <br /> <br />i ' 7b. Zip Codo <br />. 68748 <br /> <br />'I!. PART I. Enl" Iho ehaln Qlovont~..dl"_II'.lnlurlol. 01 complk:otlonl--lhl1 direet~ clulld thedeelh. 0.0 N.oT ani" lannlnolovenll lueh 0$ caldlae.o"olt. <br />'..piroloryllTest, or yontrlcular f1brill_1Ion ..Ithout $!lowing 11I0 allotogy. 00 NOT A88ReVIATE.Enl" QIlIy 0", cOulO QIl olin.. Add oddlllonolIIn..If n"'....ry. <br />IMMEDIATE CAUSE' <br /> <br />APPROXIMATE INTERVAL <br /> <br />""'0' to deolh <br /> <br />(0) <br /> <br />~V/k4"'-/~ <br /> <br />taq_Ryllol~1l <br />...,.,looocIlntlll"_/lIlad <br />on II"... <br />_"lNlERl.'IIIG CAUIlII <br />(dlatetolOt lIIjIny _..... <br />............lndlalhl <br />lAII' <br /> <br />DUE T.o. OR AS A CONSEQUENCE OF: <br /> <br />PA' ~s~ <br /> <br />I onNt 10 death <br /> <br />(b) <br /> <br /> <br />(~ <br /> <br />DUE TO. .oR AS A NSE.oUENCE .oF; <br /> <br />onsollo deolll <br /> <br />Ic) <br />DUe TO. 01'1 AS ACONSEOUENCE. .oF; <br /> <br />.nllt to deotll <br /> <br />(d) <br /> <br />, 8, PART II. OTHER SIGNIFICANT CONDITIONS-Condlllon. conlriDuling to 'ho desth bul nOI rOlulllng in Ih. und"'y,"g C,UIO glvon In PART I. <br /> <br />220. DATE .oF INJUI'IY (Mo.. D.y, V,.) <br /> <br />'I' 210. MA~R OF DUTH <br />IZ'N_IUrol 0 Homicide <br />I <br />I <br />I <br /> <br />i <br />I <br />: 22b. TIME .oF INJURY ! 22c. PLACE OF INJURY.At hO"'I. form. II'..'. loeWy, ollico blIlloing. conllrUClion lilo. alc. (Spoclfy) <br /> <br />I m <br /> <br />a AccidenlO POndlng.lnv..tiQo.IQIl <br /> <br />19. WAS MEDICAL ExAMINER <br />.oR C.oROHER C.o~~.crED? <br />o YES :YN0 <br /> <br />I 21 b. IF TRANSP.oRTATl.oN INJURY I 21c. WAS AN AUT.oPSV PERF.oRMED? <br />: ':I Drive'/Operolo' . . / <br />! :J P....nger ,0 V E S 7: N.o <br /> <br />I 0 Ptdtll"an 21d. 'MiRE AUT.oPSY FINDINGS AVAll.A8I.E TO <br />OQther(SPIIllfy) I COMPLETE~OFOUTH? <br />! <br />. iJ YES :J 101.0 <br /> <br />20. ~MA~E; <br />.<INo. plegnant wiU'Un p.,' yel' <br />o Progn.nt It limo of doolh <br />o 10101 prognanl, Dut prognenl ..ilnin 42 deyl of dOalh <br />o Not prog"""l. bUI pregnanl13 doyo 10 , _ before dulll <br />iJ Unkn...n It pregnont "I.thin tho PO.I YO" <br /> <br />CJ Suicid. 0 Could IIOt be deten",nOd <br /> <br />22.. DescRI8e HOW INJURY OCCURRED <br /> <br />a yes CJ HO <br /> <br />221. LOCATION OF INJURY - STREET I HUM8ER, APT. NO. <br /> <br />CITY /TOiI1II <br /> <br />i1l\TE <br /> <br />ZIP CODE <br /> <br />'~I.I.t...... <br />4r <br /> <br />121.. DATE SIGNED (Mo.. Doy. Yr.) <br /> <br /> <br />24.:, PRONOUNCED DEAD (MQ., Day, YI.) <br /> <br />24D. TIMe OF DEATH <br /> <br />m <br /> <br />21d. TIM!' PRONOUNCED DEAD <br />m <br /> <br />241. On Iho balil of o._m,n"lon and/ol inYOltlQotlon. In my oplnlQll deOIll """uned ot <br />lIle lime. d..o ondpite. .no d~. to.lhe COUII(I) ...ted. ISiVnotura 'nd Tille) " <br /> <br />28b. WAS CONSENT GRANTED' <br /> <br />it <br /> <br />This certifies this document to be a true copy of an original record on file with Vital Statistics, Douglas County <br />Health Dept., Omaha, Nebraska. Certified copies must have a raised seal in the area to the left. Reproductions <br />of this green ;;ertificate are not legal copies. <br /> <br />Date Issued: <br /> <br />AUG 0 3 2006 <br /> <br />Registrar: <br /> <br />A~.j <br /> <br />::J ...." <br />O,~ <br />