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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SEI1YICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORO:JJN;FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSriCSSECTlQN;-WlJICH IS
<br />
<br />
<br />::~~~:77~:ORY FOR VITAL RECORDS ~!~~~R
<br />200704960 4SSISTANTSTiifE-FiEGISTBjJ,R
<br />HEALTHjJ,ND HUMAN SEFt1/{CES
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINAOCE-'AND SUP'P ,.
<br />CERTIFICATE OF DEATH
<br />
<br />Midulsl
<br />
<br />Last,
<br />
<br />SUlllx)
<br />
<br />2.SEX
<br />Female
<br />
<br />'03.TIATE OF DEATH (Mo.. D.y, Yr.)
<br />December 4, 2006
<br />
<br />6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />
<br />I. DECEDENT'S-NAME (Flrsl,
<br />Ella Jean Olsen
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE.Lasl Blrlhday
<br />IYrs.)
<br />
<br />5b. UNDER I YEAR
<br />MOS. DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />Gibbon, Nebraska
<br />7. SOCIAl SECURITY NUMBER
<br />
<br />83
<br />
<br />July 1,1923
<br />
<br />8a. PLACE OF DEATH
<br />~:
<br />
<br />D Inpallenl
<br />
<br />OTHER: U Nursing HomelL TC D Hospice Facility
<br />
<br />506-20-4529
<br />
<br />Bb. FACILITY.NAME (If not Institution. give str..t and number)
<br />
<br />Llll ER/Oulpallenl
<br />
<br />D Decedent's Home
<br />
<br />SI. Francis E.R. 2620 W. Faidley Avenue
<br />'" -,-"
<br />Be. CITY on TOWN OF DEATII Ilnclude Zip Code)
<br />
<br />DCOI
<br />
<br />U OU1er(Speclry)____
<br />
<br />ed. COUNTY OF DEATH
<br />
<br />Grand Isiand 68803
<br />9a. RESIDENCE-STATE
<br />
<br />
<br />68801
<br />
<br />-'r::~UNTY
<br />
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />
<br />91. ZIP CODE
<br />
<br />9g.INSIDE CITY I.lMITS
<br />I)j YES D NO
<br />
<br />1405 W Highway 3,1 ..-
<br />lOa. MARITAl STATUS AT TIME OF DEATH 0 Married D Nev.r Married
<br />
<br />lOb. NAME OF SPOUSE (Firsl. Middle, Last, Sulllx) II wile, give maiden name.
<br />
<br />D Marned, bul sepamle(J GiI Widowed 0 Divorced D Unknown
<br />
<br />I I. FATHER'S.NAME (Flrsl,
<br />Verne Sherard
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />Sulli>)
<br />
<br />12. MOTHER'S.NAME (Flrsl.
<br />Edna Keecher
<br />
<br />Middle,
<br />
<br />Malden SUrname)
<br />
<br />13. EVER IN U.S. AHMED FORCES? Give dol.. 01 service ilyes. 14a.INFOnMANT-NAME
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />
<br />16c. DATE (Mo., Doy, Yr.)
<br />
<br />Decem~er 7, 2006
<br />STATE
<br />
<br />IYes, no, 01 unk.) No
<br />IS. ME IHOD OF DISPOSITION
<br />~url.1 ODonollon
<br />
<br />Sharon Jensen
<br />16a'''fBAlMER'SIGNATURE .', -F6b.LICENSENO 1143
<br />."."~R. ~~~__~-
<br />
<br />16d. CEMUERY, CREMATORY OR OTHER LOCATION CITY I TOWN
<br />
<br />o Cremation 0 Entombment
<br />
<br />Nebraska
<br />
<br />U Removal D Olher (Speclly)
<br />
<br />Westlawn Memorial Park Cemetery
<br />
<br />Grand Island
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slteel. Clly orTown, Slale)
<br />Livingston.Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />
<br />17b. Zip Code
<br />68803
<br />
<br />CAUSE OF DEATH (See instructions and examples)
<br />
<br />18. PART I. Enle,lhe ~~ndlsease', injUlles, or complle.llonsntl,,1 directly caused Ihe de.lIl DO NOT enler lermlnal evonls such as cardiac arrest,
<br />respll"lolY anest. orvenlricular Ilbrlllal!on wllhoul showing Ihe etiology. DO NOT ABBReVIATE. Enl", only one cause on a line. Add addllionalllnes II necessary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMErJlATE CAUSF.:
<br />
<br />I
<br />I
<br />
<br />: )!(>sel 10 dealh
<br />
<br />IMMEDIATE CAUSE (Fklal
<br />disease or condition resulllng
<br />Indeelh)
<br />
<br />(a) .J tJ'2J {~ .;
<br />n_____.._.__.,___.21;,l::_..__.~________..______...
<br />DUE TO, on AS A CONSEOUENCE OF:
<br />
<br />I 'j
<br />.----15::..I::YI'qLYi! Cf
<br />
<br />onsello death
<br />
<br />Soquentlatly lIst cOlldltlons, 11 (b)
<br />.IlY, leading 10 Il1e e.usen.ted DUE TO. OR AS A CONSEOUENCE 01"
<br />on lI11eo.
<br />Ent.r U1e UNDERlYING CAUSE
<br />(disease or 1I1lu'1 tl1.1lnlllaled (e)
<br />111. evenlsresultlng In dean,) DUE TO. OR AS A CONSEOUENCE OF:
<br />fAg!'
<br />
<br />onsel to cJealh
<br />
<br />(t!)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS.Candlllons conhibullng 10 Iho de.111 bul nol re.ulllng In Il1e underlying causo gIVen In PART I.
<br />
<br />ijkWAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?,
<br />,
<br />U YES 'tl{ NO ...
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<br />2~F FEMALE:
<br />
<br />
<br />tl Nol pregnanl wllhln past year
<br />
<br />o pregnanl at limo 01 deall1
<br />
<br />o Nol plegnant. but pregnant within 42 doys 01 deall,
<br />
<br />D Nol Plegnonl, bul pregnanl43 days 10 1 yearbelore dealh
<br />
<br />Q_ ~n~nqwn..ir'p'r~qtH'tlL\yj1tli.~~~'pa?1 ye~~ _ _.__
<br />
<br />1\' MANNER OF DEATH
<br />/ "1!l..Naturol U Homicide
<br />
<br />[J AccldontD Pending Invesligolion
<br />
<br />U Suicide 0 Could nol be dolermlned
<br />
<br />2-J,b.I,F rRANSPORTATION INJURY 2J<<)- WAS AN AUTOPSY PERFORMED'
<br />/ U Driver/Operalor (
<br />o YES )rJ NO
<br />
<br />U Passenger
<br />
<br />U Pedeslrlan
<br />o Other (Speclly)
<br />
<br />:Xi. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPlETE CAUSE OF DEATH?
<br />o YFS )ij NO
<br />
<br />22a. DATE OF INJURY (Mo.. D.y, Yr.)
<br />
<br />22b. TIME OF INJURY
<br />
<br />22C. PLACE OF INJURY-At home, larm, slreel, I. clary. olllce building, conslrucllon site, elc.ISpeclly)
<br />
<br />~
<br />
<br />22d.INJURY ATWOflK'J
<br />
<br />m
<br />1220. DESCRIBE HOW INJURY OCCURRED
<br />I
<br />
<br />ZIP CODE
<br />
<br />[J YES D NO
<br />
<br />221.l.OCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
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<br />
<br />24a. DATE SIGNED (Mo., Uay, Yr.)
<br />
<br />24b. TIMe OF DEATH
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo.. Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On lhe basis 01 examlnallon and/or Investigation, In my opinion dealh occurred al
<br />lI,e tlmo, dale and place and due 10 Ihe cause(s) staled. (SlgnaIUt. and Tille)"
<br />
<br />~. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED'
<br />
<br />~. WAS CONSENT GRANTED?
<br />Not Applicable 1126a is NO D YES NO
<br />
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