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<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANQ IiUMA NSER VICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINM.VtEcaifD'GN FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STiifSTiCS'SECTION;:WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ....i=~. c.. . . . '0'1.. ":.u.. ........
<br />
<br />DATE OF ISSUANCE . . 011Af.&.u,:;. ~I>.v
<br />JAN 2 4 2007'~~'!'~jJ:rlt~~y Si'Cd:,PER
<br />5 3 4 ; ASS!STANT STATE FlEGISTRAR
<br />LINCOLN, NEBRASKA 20070 6 Hp4LTH. AND HUMAN SEi!VICES
<br />
<br />
<br />. .
<br />STATE OF N. EBRASK..A -... DEPARTM. E... NT OF HEAL..T. H AND HUMAN SER.VI.CES FIN... ANCEAND SUPPOR.. T ." '7. .
<br />._____ _ _CE.~TIFI~ATE OF:.DEATH. 01--.2024--L-
<br />1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo" Day, Yr.) ,~
<br />___ Ha;r-olp. ~<?_r~ Se~m _ _ .Male January 14,?OOF_
<br />
<br />4 CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRT~r AGE-Laat Birthday 5b UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Merrick County, Nebraska --..l(Yts) 89 MOS'l~ HOURS MINS M~rCh ~~9~
<br />
<br />7 SOCIAL SECURITY NUMBER fa PLACE OF DEATH
<br />529- 1 6 - 3 8 6 8 ~. 0 InpetiBnt QlliE8; ~ Nursing Home/LTC [j Hospice Faclllly
<br />
<br />-B~;:~~1;"~~~rt!:~'~"r~;'_Lr~ek~~nl_'~~ ~ _ - __ W ER/Outpallent 0 Decedent's Home
<br />
<br />W [l)I\ 0 Other (Specity)
<br />
<br />8c. CITY OR TOWN OF DEATH (IncludB Zip COdB) ~d. COUNTY OF DEATH
<br />
<br />G!an_dlsla~8801 . L.H~
<br />9..~lllruCE-S.T~Ii,'a - -~U~ --~YORTOWN
<br />1.~D~d_~ _I~ll ~_~rand Island
<br />
<br />9d1s0R;ETA~D.NUM1E6th -~. -~~- _- = -1ge APT N~C;~Ol
<br />
<br />
<br />,.. """" """' """' 0> ""lli 0 "moO 0 ,,"' "'""T '^" 0> "'"" (0,". '"'' ~, '""" ""<'. ,,, ",,,..,,.
<br />
<br />
<br />o Married, but saparated }Q Widowed U Divorced U Unknown
<br />
<br />
<br />". FATHER;S-NAME (Fi;~-" Middle, -~-;, SUfft;~MOTHER'S-NAME (Flr~;:-- Mlddle,-------;;,~iden surn~-m~)
<br />___.~_J.ohn ..... Sl?~. .~_ _ Clara Gi~senh~gen
<br />, ~EVER IN U.S. ARMED FORCES? Giva dates 01 servica if yas. 14a.INFORMANT-NAME
<br />(Yas~~OrUOk) 4/1941-11/1945 John Seim
<br />
<br />---;-; METHOD OF-DISPOSITION ]6B '~LMER.siGNrryREI\ ,71. ~ -~ENSE NO--
<br />~Burlal o Donation k~f.fJ!--!L; l~rH -.L1071
<br />
<br />o Cremalion 0 Entombment Hid CEMETERY, CREMATORY DR OTHER LOCATI~ - ----;;;:y; TOWN
<br />
<br />URemoval OOthar(Speclly) Westlawn Memorial Park Cemetery Grand Island
<br />
<br />--.."'...---- -- - ----
<br />170. FUNERAL HOME NAME AND MAILING ADDRESS (Slraat, City orTown, State)
<br />All Faiths Funeral Home 2929 South
<br />
<br />-~g.INSIDE CITY LIMITS
<br />I Xl YES [j NO
<br />.,---_.._,.,--
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />
<br />16c. DATE (Mo., Day, Yr.)
<br />January 18,2007
<br />
<br />STATE
<br />
<br />NE
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<br />18. PART I. Entor the P.b..a.ln...QL1iv:en.ts--dlseasBs, injuries, or complicatlons--that directly caused the death, DO NOT enter terminal events SlJch as cardiac arres!,
<br />respiratory arrest, or ventricular fibrlHallon without showIng the etiology, DO NOT ABBREVIATE. Enter only onB cause on a line. Add addltlonallines If necessa.ry.
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />
<br />';.\::,,'
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />I
<br />I
<br />
<br />I onselto death
<br />I
<br />I
<br />._~-
<br />I onset to death
<br />I
<br />
<br />: ~-du_
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />Indaath)
<br />
<br />__~ __...J::M:.Cf<::A'
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF;
<br />
<br />Sequontl.lly list conditions, if (b) ~ ",^^-. tr j'{flrv\
<br />any,IBadlngtothacaUSBllsted -DUE TO, OR AS A CONSEQUENCE~-
<br />on line 8.
<br />Entertho UNDERLYING CAUSE fI . . ..,l;:,
<br />(dl...se or injury that Inlll.ted (c) ~....Q.)>...-I\\ 0---
<br />tho events resulting In death) --. DUE TO OR AS A CONSEOUEN6~--
<br />lAST ' .
<br />
<br />I onsalto death
<br />
<br />I
<br />
<br />'Nl~
<br />_...-.~_.-._._._.-..
<br />onsat to death
<br />
<br />(d)
<br />18. PART II. OTHER SIGNIFICA-NT CONDITIONii:ccinditions oO~lributing to tha d~~thbut not reSU;1in~ in Ihe unda;l~ing cause ~iv~n In PART I.
<br />
<br />~
<br />~
<br />'-:.:J
<br />
<br />
<br />20. IF FEMALE: 21a. MANNER OF DEATH 21b.IFTRANSPORTATlON INJURY 210. WAS AN AUTOPSY PERFORMED?
<br />IV Nalural U Homicide 0 Driver/Operator
<br />o Not pregnant within past year'" 0 YES ~NO
<br />o Pregnant at time of death 0 AccldenlU Pending Invesligation [J Passenger -.-.- "-~
<br />o Not pre9nant, but pregnant within 42 days ot death 0 Suicide U Could nol be datermined 0 Padestrian 21d. WERE AUTOPSY FiNDINGS AVAILABLE TO
<br />o Not pragn.nt, but pregn.nt43 days to 1 ya.. before dealh 0 Other (Specify) COMPLETE CAUSE OF DEATH?
<br />o Unknown if pregnant within tha past year _. ._. .._ [j YES U NO
<br />~2a DATE_OF INJU_RY (MO_' Day, Vr) ~_ 122~_ TIME-OF INJUR-~2~. PLA:E OF INJ~~Y.At h~me, ferm, street, feclory, olllce building, construction Slt~-;tc (Specify) -
<br />
<br />22d INJURY AT WORK? 122e DESCRIBE HOW INJURY OCCURRED
<br />[J YES 0 NO
<br />--- ~"-'- .....-...-.
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT NO. CITYITOWN STPJ'E ZIP CODE
<br />
<br />'19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />[J YES 00- NO
<br />
<br />23a. OAr OF DEATH (Mo., Day, Yr.)
<br />
<br />-- \_~J\)~
<br />23b.DA E SIGNED (Mo" Day, Yr.)
<br />\ 0
<br />
<br />24a. DATE SIGNED (Mo., Day, Yf.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />z>-
<br />!'~~
<br />_0:
<br />""'p
<br />n~
<br />c.a....:(~
<br />E."' j': Z
<br />8ffizO
<br />"z=>
<br />.coo
<br />~a:o
<br />8ll
<br />
<br />m
<br />
<br />230. TIME OF DEATH
<br />J.DQ'O
<br />
<br />24c. PRONOUNCED DEAD (Mo.. Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To Iha best of my knowledge, dea'h occurrad althe lime, d.ta and place
<br />.nd due to 'he c.usa(s) stated. (Slgn~ture and Tilla) T
<br />
<br />24e. Onlhe basis of examination and/or invBstigallon, In my opinIon death occurred at
<br />the lime, data and piece and duato the causa(s) stated. (Signature and Tllla) T
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTW?
<br />
<br />_ U YES ~.NO_~B~~l!.NK~OWN __. 0 YES .. _ _~_~O__. .___ Not Appllcabla it 26als~~~S_~.
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONIOR'S PHYSICIAN OR COUNTY ATTORNEY) (Typa or Prinl)
<br />Dr. Sara Graybill 2116 W. Faidley Ave. Grand Island NE 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />JAN
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