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<br />..
<br />
<br />STATE OF NEBRASKA
<br />
<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 STATIST'lCSSECTJON, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. N:~, ,f-ll'~, .~, ,
<br />
<br />~~~~~~ ~C~~l~~; ,
<br />DEe 192007 200804530 A~~::-:#~
<br />
<br />LINCOLN, NEBRASKA Hl;:liLtfiI ~lJ HuMAN SERlIICl8
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEJU.TH AND HUMAN SERVICES;;riN~:~ ,I"'" " ~
<br />CERTIFICATE OF DEATH~',;,'~~": '... .:
<br />
<br />~
<br />
<br />
<br />~I. AGE-Lal BitlhdlY
<br />(VII.)
<br />
<br />
<br />sum,.
<br />
<br />~
<br />
<br />llidd18,
<br />
<br />L.ltt.
<br />
<br />Pocatello Idaho
<br />7, SOCIAl. SECUFITV NUMBER
<br />, 506-26-7822
<br />
<br />77
<br />81 PLACl; OF 010liTH
<br />HOS.el1M.:
<br />
<br />1928
<br />
<br />[J Inpallonl
<br />
<br />mIfB: :il NUI1III1ll Homo.1.TC [J _,"co ~1C11Iy
<br />
<br />8b. FAOILlTY-NAME (II not inlrllutlon, give ar"" end number)
<br />
<br />[J ERlOutpelleru
<br />
<br />Q 0""'_1 Home
<br />
<br />-'~~"'""",,-.-'-:'.....-;. ;:;.'1""''''''~~ ..,.;-,~,'-....".
<br />Center [J IXl' Q O\IItr l$pacly,
<br />80: OITY OR TOWN OF DEATH Ilncludl Zip Codl) 8d, COUNTY OF DEATH
<br />Lincoln 68506 Iancaster
<br />iItl.OOLMY
<br />
<br />,....::...,..... "l".!
<br />
<br />Nebraska
<br />
<br />Hall
<br />
<br />
<br />9g, INSIDE CITY L.IMITS
<br />!it YES [J NO
<br />
<br />!/d.~~AMIN~
<br />1212 west Koeni Street 68801
<br />101, MARITAL. ST1J\JS AT TIME OF DEATH :i!l.llirrlod Q _loIarrlld lOb, NAME OF SPOUSE 'IF;,", MlddIa, LaoL. lM""1 n """. 9"'" m.ldln nome.
<br />
<br />a MelTkld, bUIIOp"'lIod Q WIdcwod a DIvon:od 0 U'*nown
<br />
<br />", FATHEf!'S.NA..1i ("Irot. Middle. Lul,
<br />Bis
<br />13. EVEAIN U,S, ARMED PORCES7 Gi'I. dll"OI IIrrtc. It,...
<br />No
<br />15. METHOD OF OISPOsmON
<br />a BinlI a Dco8Ilen
<br />alerom.licn 0 EnlO..bmonl lSd. OEMETERY. OREMAlOlIY OR OTHER LOCATION
<br />
<br />
<br />Daniel Liebsack
<br />S.ltll) . 12_ 1I0THER'S-NAME (FI..., Mlddlo, M&ld.n Su.n....)
<br />Mae Lauritsen
<br />
<br />Ub, REL.ATION~HIP TO DECEDENT
<br />
<br />Husband
<br />lee. DATE 11010" D.y, y, I
<br />11-4-2005
<br />
<br />OITY I TOWN
<br />
<br />STATE
<br />
<br />a_ ~OUl"I~pecilyl
<br />
<br />Grand Island Cit
<br />171. FUNERAL. HOME NAIIE AND lIAJLlN~ AllDIl~S <_. CIIy 0,Ti:l..... S....)
<br />
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />17b_ Zip OC<le
<br />
<br />68801
<br />
<br />. APPROXIMATE INTERVAL.
<br />
<br />"MEllL'J1!! CAUSE,
<br />
<br />(0) C. ltY'dt'arlAlmo n~
<br />DUE TO, OR AS A C~OUENCE OF:
<br />
<br />DUE TO.
<br />
<br />
<br />
<br />~.
<br />
<br />. en..II._
<br />I
<br />I dCI..-.
<br />
<br />........., .............11
<br />..,....._ID..__
<br />onlm&
<br />em."\KIERmIGc:.uE
<br />~"hrJlrlhI_
<br />..-......~~
<br />UIllr
<br />
<br />rI'1..~
<br />
<br /><k1}--
<br />
<br />....110 _
<br />
<br />'~U"71 fh..t
<br />
<br />en..I'o_
<br />
<br />(Cj C'..A.YcU ~C &\;\. MV R.
<br />OLJ; TO. OR AS A OONSEQlIEf>IOE 0
<br />
<br />(II) c:.o /0 ni C- / Ie /AS
<br />
<br />ivR..
<br />
<br />c....~ ~/)
<br />
<br />n"\.O'T" n-u
<br />
<br />I enllll._",
<br />
<br />rn CTYI 1M
<br />
<br />gLliICIIPlIlInant vrilhlnp8ll ysor
<br />[J P,.lnllt ton. 01 dooth
<br />1;;1 Nlll prsgnlnl. but prognanlllltllln 42 day$ ctdoatn
<br />[J liI..p..."....,butpllllnl/'ll043d1I'1"'Ir-__h
<br />[J Unknown. ",,"O_t "itlin tnO pili yoar
<br />
<br />210, MANNER OF DEATH
<br />:Jlil Net...el 0 Homicldl
<br />
<br />[J AocId.nl[J Pondll1; 1"",,"liOIlI..
<br />
<br />OSuldd. [Jo.'ldnctb""IInn1111Ct
<br />
<br />10, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />a YES JiI NO
<br />
<br />21b IFTAANSPOR1l\TION INJUR'/21o;. WAS M1AUTOP$Y PEAFORMED'I
<br />I:J OriverlOiltlIIOf
<br />
<br />p~ ~on...r
<br />
<br />CW(h'c..-
<br />
<br />voJ.Y'€.
<br />
<br />~"(ck-hs, CA.r..L.rrv.'~
<br />
<br />!J p_.,
<br />[J p._iln
<br />
<br />C OtIIIljSpscIly)
<br />
<br />o YES "'S-NO
<br />
<br />. ~~~.,
<br />
<br />21d_ WEAEAlITOPSY I'If1DlNGSAVAt.ABl.E TO
<br />
<br />OOMFlET'EOAUSE OF~?
<br />o VES 0 NO
<br />
<br />22c. PLACE OF INJUlIY-Al homo, hU", s"..~ hIc1o'~, clflco building, ceoll1rUClion ...., .Ic. (SpIC,ly)
<br />
<br />CITY/TO'f/III
<br />
<br />S1m
<br />
<br />ZIP COIlE
<br />
<br />2.... DATE SIGNED (Me.. DIV. Yr.)
<br />
<br />M'. TIME OF DEATH
<br />
<br />fIIi
<br />=I~
<br />
<br />m
<br />
<br />NIl. PRONOUNCED llEAIl lllc., Day. Yr.) 24d. TIME PAONOLH:ED DfAIl
<br />m
<br />
<br />2401. On tho Iloo11 '" .....__.. ~~IIIcn, In my opIr/Cn dNlh o....,ad II
<br />thltimt.dlItund p1oc:a llId dualo IhlClUI8(1) ,LaIad. fSlgnolln Ind llUo I .,.
<br />
<br />261 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED'! 28b. WAS CONSENT GRANTED?
<br />
<br />
<br />Nol Applicable 112S& I. NO a YES [J NO
<br />
<br />Street.
<br />
<br />NE - 6S506
<br />
<br />2l1b. DATE FILED BY REGISTFIAR (....-. D.oy. y,_)
<br />
<br />NOV 0 7 2005
<br />
<br />1;H$-611t/03 (MOllll
<br />
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