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<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 ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE ? ; .
<br />OCT 0 3 2007 200709681 '''r
<br />AS&�I41$§1 Nj�
<br />LINCOLN, NEBRASKA HEM AW.. R 99R, 96
<br />STATE. OF NEBRASKA -- DEPARTMENT OF HEALTH AND HUMAN SERVICES FI91*E P + '
<br />CERTIFICATE OF DEAT Qt
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix) 2:8
<br />E •
<br />DA7EOF.&k1TH,(jJo.,bay,Yr)
<br />Terry Lou Larson
<br />Fe d•; 4
<br />'^ la %rditY$i 20 2007
<br />r(Mo..
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />6a. AGE-Lasl Birthday
<br />Sb. UNDER 1 YEAR So.
<br />UNDE11.11)4
<br />1yr W o BIRTH Day, Yr.)
<br />(Yrs,)
<br />tF -k•
<br />MOS.
<br />DAYS HOURS
<br />Ml ft,
<br />Grand Island, Nebraska
<br />71
<br />November 23, 1935
<br />7. SOCIAL SEOURITY NUMBER
<br />Ba, PLACE OF DEATH
<br />507 -36 -3491
<br />HOPITAL: © Inpatient OTHE9 [3 Nursing Home/LTC ❑ Hosploe Fadllty
<br />81b, FACILITY -NAME (If not Institution, give street and number)
<br />cc
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />Saint Francis Medical Center
<br />❑ Don ❑ omer(specry) _..____
<br />8c, CITY OR TOWN OF DEATH (Include Zip Code)
<br />8d, COUNTY OF DEATH
<br />Grand Island 68803
<br />Hall
<br />8a, RESIDENCE-STATE
<br />9b. COUNTY
<br />ec. CITY OR TOWN
<br />Nebraska
<br />Hall
<br />Grand Island
<br />'p
<br />Bd. STREET AND NUMBER
<br />Be. APT. NO
<br />ef. ZIP CODE
<br />99. INSIDE CITY LIMITS
<br />3440 Graham Ave.
<br />68803
<br />Cif YES ❑ NO
<br />10a, MARITAL STATUS AT TIME OF DEATH W Married ❑ Never Married 10b,
<br />NAME OF SPOUSE (First. Middle, Last, Suffix) II wife, give maiden name.
<br />S
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />�
<br />David Larson
<br />11, FATHER'$ -NAME (First, Middle, Last, Suffix)
<br />I
<br />12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br />F°-
<br />Irvin P' M Ves
<br />Ruby Terry
<br />13, EVER IN U.S. ARMED FORCES? Give dates of aervlcelryes.
<br />148. INFORMANT -NAME
<br />I
<br />14b. RELATIONSHIP TO DECEDENT
<br />(Yes, no, orunk.) No
<br />David Larson
<br />Husband
<br />15. METHOD OF DISPOSITION
<br />16a., SALMER -SIG U -.
<br />t6b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />® Burial 0 Donation
<br />��
<br />� " �
<br />September 22, 2007
<br />ed-CEMETERY ?5REM RY oRbTHER LOCAfRfN CITYITOWN STATE
<br />❑Cremation Z1 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />Grand Island City Cemetery Grand Island Nebraska
<br />178. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, state,
<br />17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events -- diseases, Injuries, or complications- -that directly caused the death. 00 NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />I
<br />respiratory arrest, orventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enteronly one cause on a IIne,Add additional lines if necessary. I
<br />IMMEDIATECAUSE: I onset to death
<br />• I
<br />IMMEgU1TECAUSE(Fhel (a) I
<br />disease orcondalonresultIng DUE TO, OR AS A CNIIISEQUENOE OF: I onset to death
<br />In death)
<br />Sequentially list conditions, B (b) l
<br />my, DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />linea.nptothacaueelbtad
<br />on line a.
<br />I
<br />Enbr are UNDERLYINGCAU8E
<br />(disease orinjury that Initiated (r:) l
<br />the events resulting hdeath) DUE TO, OR AS A CONSEQUE NC E OF: I onset to death
<br />LAST
<br />I
<br />(d) 1
<br />18. PART IL OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART 1.
<br />19, WAS MEDICAL EXAMINER
<br />(Y s-xig -p- -_ur lccl
<br />OR CORONER CONTACTED?
<br />❑ YES 9 NO
<br />20. IF FEMALE:
<br />21a NER OF DEATH
<br />,)11�l
<br />21b. IF TRANSPORTATION INJURY
<br />21c, WAS AN AUTOPSY PERFORMED?
<br />Not pregnant within past year
<br />atural ❑Homicide
<br />❑Driv."Operator
<br />❑YESND
<br />L) Pregnant at time of death
<br />❑ AccldentQ Pending Investigation
<br />❑Passenger
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />.1�
<br />❑ Not pregnant, but pregnant within 42 days Of death
<br />❑ Suicide L] Could not determined
<br />t,1 Pedestrian
<br />❑ Not pregnant, but pregnant 43 days to I year before death
<br />❑Other(spedry)
<br />COMPLETE CAUSE OF DEATH?
<br />❑ unknown it pregnant wl thin the past year
<br />❑ YES ❑ NO
<br />22a, DATE OF INJURY (Mo., Day, Yr.)
<br />22b, TIME OF INJURY
<br />220, PLACE OF INJURY -At home; farm, street, factory, office building, construction site, etc. (specify)
<br />M
<br />1
<br />k
<br />22d. 114J LAY AT WORK?
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES LINO
<br />221. LOCATION OF INJURY - STREET& NUMBER, APT. NO. CITYfMN STATE ZIPCODE
<br />23a, DATE OF DEATH (MO., Day, Yr,)
<br />z y 24a. DATE SIGNED (Mo., Day,Yr,) 240.
<br />TIME OF DEATH
<br />Se tember 20 2007
<br />M
<br />m
<br />236. DATE$IGryED
<br />(MO., Day, Yr.)
<br />23c. TIME OF DEATH
<br />_
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d.TIMEPRONOUNCEDDEAD
<br />1
<br />Ib�
<br />1:IS A• m
<br />r
<br />IL m
<br />LII
<br />23d. To the best of my knowledge, death occurred al theTlme, dale and place
<br />-S
<br />05 24e. On the basis of exarianation and /or investigation, In my opinion death occurred at
<br />and due to the cause(s) stated. (Signature and Title) r
<br />U the time, date and place and due to the cauae(s) stated. (signature and Title ) V
<br />05
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED
<br />26b. WAS CONSENT GRANTED?
<br />126a.
<br />❑ YES NO ❑PROBABLY ❑ UNKNOWN
<br />❑ YES NO
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />27. NAME ,TITLEANDADDRESSOFCERTIFIER( PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY TTORNEY)(TypeorPnnt)
<br />Heather Hockman, M.D. 3016 W. Faidley Ave., Grand Island NE 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />P
<br />SEP 2 4 2007
<br />
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