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<br />, ..
<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 RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~.... ..... ..... . ..............1 '.4'L~." .' ...... ". J~.... '"
<br />
<br />DATE OF ISSUANCE . ..fI}.. '.....,'
<br />,... . TANL'cYrEk:,coR~fl
<br />FEB 11 2008 200804158 ASSi!3T.iWt.$fAfEREGIS"'{MI
<br />LINCOLN, NEBRASKA HEALrH74~ HUMAN SERVtCE.S;
<br />. ~ --~~ '{;: '. t.-,::';j
<br />'--, > .~;, ./'1., ' , ;' ~:: '~
<br />
<br />!" "- ~. '.
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FIN1I"NCE AND SUPPa " '0' 3
<br />CERTIFICATE OF DEATH ' . ,I, , '
<br />2. sex. <:,1',' '3:~QF. EATH' (Mo.. Day, Yr.)
<br />Fema1!"""" 'q~ 12, 2008
<br />
<br />Mlddlo.
<br />Bernice
<br />
<br />Last,
<br />Be1tzer
<br />
<br />Suffix)
<br />
<br />. ~.
<br />
<br />~
<br />
<br />
<br />1. DECEDENT'S'NAME(Flr$t,
<br />Anita
<br />
<br />4. CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE.La.t Blrthdoy 5b. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />91
<br />
<br />5c. UNDER 1 OA\<
<br />HOURS MINS.
<br />
<br />8. DATE OF BIRTH (MO.. Day. Yr.)
<br />
<br />Minneapolis, Minnesota
<br />
<br />August 20, 1916
<br />
<br />7. SOCIAL SECURITY NUMBER-
<br />531-01-0730
<br />
<br />Sa. PlACE OF DEATH
<br />~: a InpaUont
<br />
<br />aII:lEB: II: Nur.lng Homo/LTC a Hospice Facillly
<br />
<br />8b. FACILITY-NAME (If not in.tltution, give stre.t and number)
<br />
<br />Cl ERiOutpatl.nt
<br />
<br />o Decedent'o Home
<br />
<br />Heritage Ball
<br />
<br />ClOOi\
<br />
<br />[J Other (Specify)
<br />
<br />8d. COUNlY OF DEATH
<br />Custer
<br />
<br />8c. CITY OR TOWN OF DEATH (Includa Zip COdo)
<br />Broken Bow, 68822
<br />
<br />9s. RESIDENCE.srATE
<br />Nebraska
<br />
<br />!lb. COUNTY
<br />Custer
<br />
<br />
<br />9f.ZIP CODE
<br />68822
<br />
<br />gg.INSIDE CITY LIMITS
<br />K YES a NO
<br />
<br />9<1. STREET AND NUMBER
<br />145 Memorial Drive
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH D Morried Cl Nev.r M.rrlod lOb. NAME OF SPOUSE (First, Middle, Last. Suffix) If wlla, glv. malde" name.
<br />
<br />o Ma"lad, but sep.roted XWldowad a Divorced Cl Unknown
<br />
<br />11. FATHER'S.NAME (Flr.I,
<br />Emil
<br />
<br />Middla,
<br />
<br />Lasl. Suffix)
<br />Carlson
<br />
<br />12. MOTHER'S-NAME (Firsl,
<br />Maedi
<br />
<br />Middle,
<br />
<br />Maldan Surnom.)
<br />Royonen
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />sOn
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give data. 01 service if yes. 14a.INFORMANT.NAME
<br />(Ye.,no,orunk.) No Steve Be1tzer
<br />15, METHOD OF DISPOSITION 16a.EMBALMER.SIGNATURE
<br />08ul1.1 II:Donallon Not Embalmed
<br />
<br />18b. LICENSE NO.
<br />
<br />18c. DATE (Mo., D.y, Yr.)
<br />Jan 12, 2008
<br />
<br />o Cremation D Entombm.nt
<br />
<br />16d, CEMETERY. CREMATORY OR OTHER LOCATION
<br />
<br />CITY I TOWN
<br />
<br />STATE
<br />
<br />DRemovsl aOthor(SpeCily) Anatomical Board of the State
<br />
<br />Omaha
<br />
<br />NE
<br />
<br />17L FUNERAL HOME NAME AND MAILING ADORESS (Str.el, City or Town, Sial.)
<br />Curran Funeral Chapel 3005 South Locuat Street
<br />
<br />Soquonllolly 1111 colldlllO"", If
<br />any, Ielldlngloihe couel_
<br />on llna a.
<br />Entortl1lUNDERLYNl CAUSE
<br />(dl_ or Injury thsl10lUatod (0)
<br />lha_...ultlng In ""h) . DUE TO, OR AS A CONSEQUENCE OF:
<br />LAllI'
<br />
<br />onset to d.ath
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing 10 Ihe d..lh but nOI re.ultlng in Ih. und.rlylng COuse given In PART I.
<br />
<br />o Accldenl0 P.ndlng Inv..llgstlon
<br />a Suicide 0 Could not be determlnad
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />a Drlll.r/Op.ralor
<br />
<br />D P....ng.r
<br />
<br />[J P.d.aI,lan
<br />
<br />a Other (Speolfy)
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />IJ YES . NO
<br />21c. WAS AN AUTOPSY PERFOR~ED?
<br />
<br />20. IF FEMALE:
<br />.l( Not prognant within past year
<br />o Preg"snto' tlm. of de.th
<br />a Not pregnant, but pregnant within 42 day. of d.sth
<br />o Not pregnant. but pragnont 43 deys to 1 yesr before d..th
<br />q,ynknown il pr.g~ant within Ih! p.st y!~r .
<br />
<br />21.. MANNER OF DEATH
<br />KN.tura' D Homicide
<br />
<br />o YES II: NO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAllABLETO
<br />COMPLETE CAUSE OF DEATli?
<br />DYES 0 NO
<br />
<br />22s. DATE OF INJURY (Mo., O.y, Yr.)
<br />
<br />22b. TIME OF INJURY 22C. PLACE OF INJURY.AI hom., farm, street, I.ctory. olflca building, Co".truollon site. .te. (Specify)
<br />m
<br />
<br />[J YES 0 NO
<br />
<br />
<br />22d.INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER. APT. NO.
<br />
<br />CITYITOWN
<br />
<br />$WE
<br />
<br />ZIP CODE
<br />
<br />24a. DATE SIGNED (Mo., Doy, Yr,)
<br />
<br />24b. TIME OF DEATH
<br />
<br />,Ul
<br />1I~~
<br />~~~
<br />
<br />m
<br />
<br />24<:. PRONOUNCED DEAD (Mo., Dey, Yr.) 24d. TIME PRONOUNCED DEAD
<br />
<br />m
<br />
<br />24.. On Ihe basis 01 exsml"stlon .ndlor Investigstion. in my opinion d.ath occurred st
<br />the time, dat. and placa ano aut 10 the osuse(slSIaMa. (8Ig"Stur. and 1 ill. )...
<br />
<br />o USE CONTRtBUTElOTHE 0
<br />
<br />[J YES X'NO Cl PROBABLY [J UNKNOWN 0 YES KNO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. or Print)
<br />Keith Gautreaux M.D. 145 Memorial Dr., Broken Bow, NE 68822
<br />
<br />2Gb. WAS CONSENT GRANTED?
<br />Nol Appllcabl.1f 26. ,. NO [J YES X NO
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo" Day. Yr.)
<br />
<br />FEB 7 2008
<br />
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