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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 ORIGINAL. REC(}1ilJ)oQN FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA1!BtlQSSECT..<<!N;:;-'II(HICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.. .~ ..:'.......:..-.--_ ~j;:".~ '. ,ot?iJ. ~",d~... '.=..~'....
<br />
<br />DATE OF ISSUANCE ~ir;:";jJl to. 0~~
<br />
<br />MAR 1 9 2007 ~A~lSf~1T~~t~;~:
<br />LINCOLN, NEBRASKA 200 8 0 2 2 0 9 ~i.t1:!AN~,~~~.'f$~CES
<br />
<br />~ ."' ~'~ ~'~:;': :;"2::':: ~'
<br />'_:',;.::~ .j:=- ~ ~:,,:,,:-~.-::.
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICESAN-~i6PPORT
<br />
<br />.. u. CERTlFtCATE OF DEATH ". ~ -,-' 07 ..-227-..1 3
<br />
<br />(Firsl, Middle, La.t, Suffix) 2. SEX 3. DATE OF DEATH (Mo" Dey, Yr.)
<br />Lee Grone male Mar. 3, 2007
<br />
<br />~
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<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF 8iRTH
<br />
<br />Geneva, Ne.
<br />
<br />5e. AGE.La.1 81rthdey
<br />
<br />(Yrs.) 67
<br />
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Oct. 7. 1939
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />505-44-1205
<br />
<br />80. PLACE OF DEATH
<br />l:l.Q.SJTIAl.: Xl I n p ali a n I
<br />
<br />Qll:IEB: 0 Nursing Home/LTC 0 Hospico Facility
<br />
<br />FACILITY.NAME (II nol In.,l1ullon, give .trool and number)
<br />
<br />U ERIOUlpellenl
<br />
<br />o Decedenl's Home
<br />
<br />BryanLGH West
<br />
<br />O[l)l\
<br />
<br />o Olher (Sp8cily)
<br />
<br />8e. CITY OR TOWN OF DEATH (InClude Zip Code)
<br />Lincoln
<br />
<br />9a. RESIDENCE.STATE
<br />
<br />Nebr.
<br />
<br />'1~:!a11
<br />
<br />6d. COUNTY OF DEATH
<br />
<br />Lancaster
<br />
<br />'.'~~~~N~~ ~sland
<br />... ... ~ l.~NO 91Z68SDOl
<br />
<br />lOb. NAME OF SPOUSE (First, Middlo, Last, Suftlx) If wife, give melden noma.
<br />Arlene Louise Albrecht
<br />
<br />. '-r
<br />
<br />9g. INSIDE CITY LIMITS
<br />xtll YES LJ NO
<br />
<br />9d. STREET AND NUMBER
<br />511 So. Vine
<br />
<br />.-- .-.
<br />lOa. MARITAL STATUS AT TIME OF DEATH :kI Merrled 0 Novor Married
<br />
<br />o Marrlod, bUI ,eper.led 0 Widowod 0 Divorced 0 Unknown
<br />
<br />11. FATlfER'S.NAME (First,
<br />Doyle
<br />
<br />Middlo,
<br />Ellsworth
<br />
<br />Last, Sulflx)
<br />Grone
<br />
<br />12. MOTHER'S.NAME (Flrsl,
<br />Herta
<br />
<br />Middle,
<br />
<br />Maldon Surneme)
<br />Heinrichs
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give detes ol.ervlcc if yos. 14a.INFORMANT.NAME
<br />(Yes, no, orunk.) No Arlene Grone
<br />
<br />15';:~a~OFDI~::::I::u .160.::M7M~~E 'Eie~~
<br />
<br />o Cramallon 0 Enlombmont 16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />J16b.L'CE~19; 2-
<br />
<br />
<br />CITY /TOWN
<br />
<br />16c. DATE (Mo., Day, Yr.)
<br />3-7-07
<br />
<br />STATE
<br />
<br />LJ Removel 0 Olher (Speclly)
<br />
<br />Grand Island Cemetery
<br />
<br />Grand Island,
<br />
<br />Ne.
<br />
<br />....- -
<br />170. rUNERAL HOME NAME AND MAILING ADDRESS (Slroal, Clly orTown, Slele)
<br />Funeral Home 1123
<br />
<br />PART l. Enler the .ch~jl'l..Q,fJ3.Y.all1.s,--diseasBSr InjurIes, or compllcatlon9--lhal directly caused the death. DO NOT enter terminal events such as cardIac arrasl,
<br />respiratory arresl, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE, Enter only one cause on a line. Add addltionalllnes If necessary.
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />5eVGRf. V(l-lIIUL-(\-{-l,
<br />
<br />rl-OAlc
<br />
<br /><; TT:.N t $ r~'
<br />
<br />I
<br />I
<br />I onset to death
<br />I
<br />I
<br />I
<br />I ansello death
<br />I
<br />I
<br />I
<br />I onsot to dealh
<br />I
<br />I
<br />.L
<br />I onset 10 death
<br />I
<br />I
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />IMMEDIATE CAUSE (Flnel
<br />disease or condition resulting
<br />In death)
<br />
<br />(a)
<br />
<br />Co N C ~ ~ 'n II r
<br />
<br />Ii E. ART
<br />
<br />FA- J l- VI'~ f-
<br />
<br />Sequentlelly list conditions, If
<br />any, leading 10 the eaU$e listed
<br />on IIn. ..
<br />Enterthe UNDERLYtNG CAUSE
<br />(dl..... or Injury lhetlnllleted
<br />th. ev.nl, re.ultlng In death)
<br />lA'lT
<br />
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(c)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(d)
<br />
<br />1 B. PART II. OTHER SIGNIFICANT ~ONDITIONS"CofJ,ditions conlr~bullng 10 Ihe doelh bul not resulllng in tho underlyl~g couse given In,PART I. f' 19. WAS MEDICAL EXAMINER
<br />f\ c V. \-f., M 1 v LQI Y AI a I I VI :/'UI n -h ~ " I 1) I '" h 1,1--~.s (Yl e 1\ 1"f,Ad; H u tvYj ( OR CORONER CONTACTED?
<br />~~~,~~~:-rL ih I-t r J) IFC1 f<'- I OS,}-{.G' lV'\d ,-hi 1)111',,1 1....-':.~'.~1_~ 1<>1.11 DYES ..B~NO
<br />
<br />20. IF FEMALE: 210. MANNER OF DEATH 21 b.IFTRANSPORTCION INJURY - lc. AS AN AUTOPSY PERFORMED?
<br />t.Q' Natural LJ Homicide 0 Drlver/Operalor .
<br />
<br />
<br />o Not pregnant wilhin past yaar
<br />o Pregnant alllma of dealh
<br />o Nol prognant, bUI pregnanl wilhin 42 day. 01 deelh
<br />o Nol pregnanl, bul pregnant 43 days 10 1 yoar before de'lh
<br />o Unknown il pregnanl wllhln the pas' year
<br />
<br />U AccldenlD Pending Investigalion
<br />
<br />LJ Possonger
<br />o PedoWI.n
<br />o Olher (Specify)
<br />
<br />DYES
<br />
<br />....El N 0
<br />
<br />LJ Suicide LJ Could nol be delermlned
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO N" n
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY,AI home, tarm, streel, tectory, oftlce building, conslruclion .ile, elc. (Specity)
<br />m
<br />22d.INJURY AT WORK? . -'r 22. DES'CRIBE HOW INJURY OCCURRED-
<br />DYES 0 NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO. CITYIfOWN
<br />
<br />22a. DATE OF INJURY (Mo" Dey, Yr.)
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />24.. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />,,~ ~
<br />"'!.!a:
<br />jcno
<br />iH::;
<br />~ffi~~
<br />llz=>
<br />,2~~
<br />uo
<br />
<br />m
<br />
<br />2 U tl ',"
<br />
<br />24c. PRONOUNCED DEAD (Mo., Dey, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To the best of my knowledge, death occurred al the tIme, dale and place
<br />
<br />and duo 10 the cauVe ) SIVated (, Ignoturo 0 d Title) 'I'
<br />, , "
<br />I I ~/
<br />
<br />1:-:
<br />
<br />24e. On the baSIS 01 examinatIon andfor invBslIgation, in my opinion death occurred at
<br />Ihe tlmo, dale end place end due 10 Ihe oeu,e(s) staled. (Slgn'lure and Title 1'1'
<br />
<br />25. DID TOBACCO USE CONTRISUf
<br />
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED? .{\A',"C
<br />(RITjS~'A- ,JuT /'yr.;T-'
<br />Nol Appllcoblel! 260.ls NO_~~~~~_m!:?_.~g_.___
<br />
<br />......0. YES 0 NO 0 PROBABLY 0 UNKNOWN "cf YES 0 NO
<br />27~NiiME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER;S'PHYSICiAN OR COUNTY ATTORNEY) (TYpe or Prlnl)
<br />V I V' I;;, 1< V" 1<' U L 1< ^ (l.. N I I fYl r> I 2. 3 u c '5 () V -r1f (6 57-'
<br />
<br />26e. REGISTRAR'S SIGNATURE
<br />
<br />
<br />i-I II (/) LN I NE
<br />
<br />l~5(J2..-.
<br />
<br />:R 4). IlJ.
<br />
<br />26b. DATE FILED SY REGISTRAR (Mo., Day, Yr.)
<br />
<br />MAR 1 32007
<br />
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