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<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAI..flgpOB/:)PN mE. WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS~fimii/'WlitCH. IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. .... -.ff.._."i,~C"~(;')I7td~''''\
<br />DATE OF ISSUANCE " .'" ~.. ~i-v \\
<br />AUG 1 4 2006 2 0 0 7 0 6 5 5 2 ~..~ :"'-0..' f~'~Y\;}CDOk~;
<br />ASStSJ?tN.T S!A7;gREq/~fi
<br />HEAL 1't"~NRlffJMAlt~VI9~
<br />
<br />t'~.
<br />~'...""","~ '". .......-
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />I
<br />I
<br />"'" \
<br />J
<br />
<br />
<br />DECEDENT'S-NAME (Firs!. Middle, LaSI,
<br />Albert Vernon Pierce
<br />
<br />-~~~I;~'~~~' ST~;~;~ T~RRITORY, OR FOREIGN COUNTRY OF BIRTH - - [5;-';G~"L~'1 ~;rlhday
<br />(Yrs)
<br />Lewellen, Nebraska 90
<br />
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINAN. C. E AND611E'P.0AftE...'--=.:...".2........' .8...'.1' 0' . 5'
<br />CERTIFlqA!E OF DEATH _"_""H'~__~'-'--~~' _.) _'_~-----'--.
<br />
<br />2. SEX
<br />Male
<br />
<br />SUfli')
<br />
<br />3. OATE OF OEATH (Mo.. Oay, Yr.)
<br />August 4, 2006
<br />
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />Sc, UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />
<br />February 23,1916
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />507-14-4542
<br />
<br />6a. PLACE OF DEATH
<br />1l.Q.SflIAJ.: 0 Inpallenl
<br />
<br />Ol1-lE8: IX Nursing HomeJLTC 0 Hosplc. Focillly
<br />
<br />8b, FACILITY.NAME (If not In.lltullon, give wool and numbor)
<br />
<br />Francis Skilled Care Nursing
<br />
<br />t...
<br />
<br />o En/Outpali.,,1
<br />
<br />o Decadent's Home
<br />
<br />OlXl\
<br />
<br />o Olher (Specily)
<br />
<br />8d. COUNTY OF DEATH
<br />Hall
<br />
<br />9b, COUNTY
<br />Hall
<br />
<br />9c. CITY OR TOWN
<br />Grand Island
<br />
<br />
<br />91, ZIP CODE
<br />68801
<br />
<br />9g. INSIDE CITY LIMITS
<br />. YES 0 NO
<br />
<br />1 DO. MARITAL STMUS ATTIME OF DEATH 0 Morriod 0 Nevor Morrlod lOb, NAME OF SPOUSE (Fltsl, Middle, L.sl, SUlli,) if wito, glvo maiden nam..
<br />
<br />o Married, bul separated Jl[WI~owod 0 Divorce~ 0 Unknown
<br />
<br />16b, LICENSE NO,
<br />1092
<br />
<br />MI~dle, Malden Surname)
<br />Lauritson
<br />
<br />~J--'----"--'--"----"""--_.
<br />140. RELATIONSHIP TO DECEDENT
<br />Daugher
<br />
<br />.. I 18c. DATE (Mo., Day, Yr.)
<br />lAug 8, 2006
<br />
<br />STATE
<br />
<br />11. FATHER'S-NAME (FirS!,
<br />Earl
<br />
<br />Mld~I.,
<br />
<br />CITY /TOWN
<br />
<br />o Removal o Other (Specify) Westlawn Memorial Park Cemetary
<br />
<br />Grand Island. Nebraska
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />on.ello death
<br />
<br />(a). 4''''--67 /v-?;1 i (f1'
<br />--OUEro:OR AS A ONSiQUENCEOF::
<br />
<br />~ .
<br />/-/1'" 4'/171 A 1_
<br />C/O+
<br />:;::;: A", ~ ), /("';( /JL
<br />
<br />I
<br />I - A
<br />'I" / ~<
<br />
<br />Sequ:antl3lly list eenditions,lf
<br />any, lea~lng 10 Ihe cau..II.Ie~
<br />cnlln881.
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury Ih~t Initlat~
<br />Ihe events resulling In death)
<br />lAST
<br />
<br />(hi
<br />
<br />;,-/-;j>t1~~C;("-
<br />
<br />
<br />':~ -1 d:~~~_
<br />
<br />I on,el to dealh
<br />
<br />oneello'~eath
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(c)
<br />
<br />. DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />16. PART II, OTHER SIGNIFICANT DONOITIONS.Condlllons conl,lbullng 10 Ihe dealh but nol re,ulllng In Ihe underlying cause given In PART I.
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />W YES II: NO
<br />
<br />A/~___.._."".
<br />20, IF FEMALE:
<br />o NOI prognant wllhin past yoer
<br />o Prognantalllme ot doalh
<br />
<br />o Accl~enlO Pending Invesllgatlon
<br />
<br />2t O.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />iJ Drlvor/Oporator
<br />
<br />o Passenger
<br />
<br />o YES
<br />
<br />IXNO
<br />
<br />21.. MANNER OF IlEATH
<br />!lINolural 0 Homicide
<br />
<br />Q Nol prBgn"snt, but pregnant within 42 days of death
<br />o Not pregnanl, bUI pregnant 43 days 10 1 year before ~ealh
<br />o Unknown II pregnant within Ihe past yoar
<br />22.. DAT~~F';NJURY--(MO~'D;~' Yr.) J:2:~-~~~"OF INJUR:
<br />
<br />
<br />22d.INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />o Suicide 0 Could nol be determined
<br />
<br />o PadBs1rian
<br />o Other (Speoily)
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLETO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />nc. PLACE OF INJURY.AI hom., farm, streel, laclory, ollice building, conslructlon .lIe, .Ic. (Speclly)
<br />
<br />1:1 YES 0 NO
<br />
<br />-. ~~_'.:=;"',"'IW.~;;If'":;;:.~'.'7" "."~'~,ii".'..
<br />
<br />221. LOCATION OF INJURY" STREET & NUMBER, APT. NO.
<br />
<br />CrTY/TOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />z>
<br />~~~
<br />"g?~
<br />h"l~
<br />E"'/:z
<br />SffizO
<br />llz:>
<br />,.c!~8
<br />8ll
<br />
<br />if. DIDTeB 26.. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />o YES .J<b;~ 0 PROBABLY 0 UNKNOWN 0 YES Jl[ NO __ _.
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ.or Prinl)
<br />Jane A. McDonald M 800 Alpha St., G~and Island, NE 68803
<br />
<br />24a, DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />;!!Ic. TIME OF DEATH
<br />10:55 am
<br />
<br />24C. PRONOUNCEO DEAD (Mo., D.y, Yr.) 24~, TIME PAONOUNC~D D~AO
<br />m
<br />
<br />24e. On lha basIs of examination and/or Invesllgatlon, in my opinion death occurred at
<br />the 11m., dale and place and due 10 Ihe caUSa(.) S1ala~, (Signa lUre an~ Tille)"
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />Not Applicable il 260i'_~o._~,~~S__~_~.'2.
<br />
<br />26a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />AUG 1 0 2006
<br />
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