|
<br />c:
<br />~
<br />
<br />.....
<br />
<br />r~i'
<br />
<br />a::
<br />w
<br />u:
<br />~
<br />a::
<br />w
<br />u
<br />j
<br />~
<br />.9/
<br />Do
<br />~
<br />U
<br /><I>
<br />III
<br />~'~ ~:'.,
<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NE8RASKA HEALTH AND HI.fJJeA.N SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINA!:.../iIEC'6fUi}JJtIi f!lIJEo,WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/~/f~i~.fjkfJ/'.fNHjfH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ":, ':".~( ....:~TrI~~::.:'.
<br />
<br />DATE OF ISSUANCE ~1J:-' UlV8"vv. /.'. .
<br />JUN 11 2008 200 806 515 . -f f ~;S..COO~jt "
<br />ASSlSTA t;.ire'1lEriISTR/l.fI-.
<br />LINCOLN, NEBRASKA HsA~Ml '~_VlqE1i-
<br />..."'1:. . , ~'.J
<br />
<br />STATE OF NEBRASKA. DEPARTMENT OF HEALTH AND HUMAN ('~~t,__ t1.,;\;,....-:..~0:6;' --7
<br />CERTI';;'.~ -- OF -. ,~~t'\~ '..':' .,/IOX: '/'.'rn
<br />2. SEX~,,' , J ~J ~.pA;r~.. '" ." o.,Day,Vr.)
<br />
<br />Female MElv29i'2008
<br />
<br />1. DECEDENT'S-NAME (FI"'t,
<br />
<br />Mlddl.,
<br />
<br />Sulli.)
<br />
<br />La.t,
<br />
<br />Lydia Emma Sophia Christensen
<br />4. CITY AND STATE OR TERRITORV, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />8. DATE OF BIRTH (Mo., Day, Vr.)
<br />
<br />$c. UNDER 1 DA V
<br />HOURS I MINS.
<br />
<br />$0, AGE.L..t Birthday
<br />(V",.)
<br />
<br />$b, UNDER 1 VEAR
<br />MOS, I DAVS
<br />
<br />December 7, 1929
<br />
<br />Alta, Iowa '
<br />7, SOCIAL SECURITY NUMBER
<br />
<br />78
<br />
<br />80. PLACE OF DEATH
<br />~ 0 Inpatl.nt
<br />o ERIOutpaU.nt
<br />oDOA
<br />
<br />~o Nu",lng Homo/LTC
<br />00 D..edent'. Home
<br />o Oth.r(Sp.clfy)
<br />
<br />o Ho.pl.e Facility
<br />
<br />482.38.2079
<br />
<br />lb. FACILITY .NAME (II not In.tllutlon, give .Ir.et .nd number)
<br />
<br />4011 Sandlewood Drive
<br />
<br />....
<br />i:!
<br />w
<br />Z
<br />::l
<br />IL
<br />j
<br />'tl
<br /><I>
<br />-
<br />'0;
<br />i
<br /><I>
<br />Q.
<br />IS
<br />u
<br /><I>
<br />III
<br />o
<br />I-
<br />
<br />lad. COUNTY Of DEATH
<br />Hall
<br />
<br />Ie. CITY OR TOWN Of DEATH (Includ. Zip Cod.)
<br />Grand Island 68803
<br />
<br />9a. RESlDENCE-8TATE 19b' COUNTY 190. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />Id. STREET AND NUMBER I I.. APT. NO. \lIf. ZIP CODE
<br />4011 Sandlewood Drive I 68803
<br />10.0. MARITAL STATUS AT TIME OF DEATH 0 Marriad 0 Ne..r Marriodl'Ob. NAME Of SPOUSE (First, Mlddl., . La", sumx) If wile, glva rnalden nam.,
<br />o Marri.d, but separatad 00 Widowed 0 Divorced 0 Unknown Harold Christensen
<br />
<br />11. fATHER'S.NAME (First, Mlddl., Laa~ Sufflx) 112. MOTHER'S.NAME (first, Mlddla, Mald.n Sumarna)
<br />Herman Glienke Marie Hinkeldev
<br />13. EVER IN U.S. ARMED FORCES? Give dalas of e....... If V..Tl..... INFORMANT.NAME
<br />(V.., No, or Unk.I No Robert Christensen
<br />1$. METHOD Of DISPOSITION la.. E~f'';.JI1'R-8IGNATURE 0 .... q ()/) J leb. UCENSE NO.
<br />lXIBu~.1 oooolt'On / fiOl--V'I....J C"'; 'aCI /~9 7
<br />Ooc.....mmO.....I. oEolom....... I....(CEMJTERV, CREMATORV OR OTHER LOCATION
<br />oothl~.po<lryl /"y, , 'f'
<br />
<br />T9S' INSIDE CITY LIMITS
<br />
<br />~ V.. 0 No
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Son
<br />
<br />le.. DATE (Mo., Day, Vr.)
<br />
<br />June 3, 2008
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />Iowa
<br />17b. Zip Cod.
<br />68801
<br />
<br />Elk Township Cemetery
<br />
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Streot, City or Town, Slate)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />Alta
<br />
<br />CAUSE OF DEATH (See instructions and examples)
<br />
<br />I APPROXIMATE INTERVAL
<br />
<br />I onset to death
<br />I
<br />I > J yr
<br />
<br />1*. PART 1_ Ent.r the ett.Jn of wenta' . dlM.sell, injun... or compll...tlonll. that C1ittctly e.auM'd the dll..h. DO NOT .nter termlnalllY8nt1i luch .. c;:.ardllc 111111..,
<br />rellplllltory amlll'" 01' vtmrlcular f1bl1l1atton without Showlna th. etlologv_ DO Nol "aaREVlATE. En'." only OM: caul. on . 11M. Add addltlona' lines If r\eC....ry.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />IMMEDIATE CAUSE (final A
<br />
<br />dlsea.. or condition resulting a) L -'7" Y . I I ~_ rt ". I
<br />In d..th) t':- V - .........
<br />
<br />tanc~r
<br />
<br />on..tto d.ath
<br />I
<br />I
<br />
<br />DUE TO, OR AS A CONSEQUENCE Of:
<br />
<br />SequenUally lI.t condition., If b)
<br />any, I..dlng to the cau..nsted
<br />on IIn. a.
<br />
<br />-r;,n..t to d.ath
<br />I
<br />I
<br />
<br />DUE TO, OR AS A CONSEQUENCe OF:
<br />
<br />Ent.r th. UNDERL VING CAUSE c)
<br />(dl..... or Injury thatlnlUated
<br />th. .v.nls r..ulting In d.ath) DUE TO, OR AS A CONSEQUENCE Of:
<br />LAST
<br />
<br />~n..t to d..th
<br />I
<br />
<br />I
<br />,
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />o YES lSl NO
<br />
<br />d)
<br />
<br />19. PART II. OTHER SIGNifICANT CONDITIONS.condlUon. cont~butlng to the dealh but nol resulUng In th. und.~ylng .au.. gl..n In PART I.
<br />
<br />20. If fEMALE:
<br />E Not prognant within pa.t yser
<br />o Pregnant at time of death
<br />o Not prognan~ but prsgnanl within 42 day. 01 d..th
<br />o Not pfIIgnant, but pregnant 43 days to 1 year before death
<br />oUnknown If pr.gnant wllllln the p..t year
<br />
<br />21.. MANNER Of DEATH
<br />:eg Naturol 0 Homl.ld.
<br />o Accld.nt 0 Pending Inv..tls.tlon
<br />o Sulcld. 0 Could not b. determln.d
<br />
<br />21b.lf TRANSPORTATION INJURV
<br />o Drtv..IOp.rator
<br />o Passenger
<br />o P.de.Wen
<br />o Olll.r (Specify)
<br />
<br />21.. WAS AN AUTOPSV PERfORMED?
<br />o YES OJ(No
<br />
<br />21d. WERE AUTOPSV fINDINGS AVAILABLE
<br />TO COMPLETE CAUSE Of DEATH?
<br />DVES 0 NO
<br />
<br />220. DATE Of INJURV (Mo., Day, Vr.) l22b. TIME Of INJURV T 220. PLACE Of INJURV-At home, farm. .lrn~ f.ctory, offI.. building, co....tru.tlon .lte, .le. (Spsclfy)
<br />
<br />
<br />. 22dJ:VAb:RK7\ ~~D~SC~~~~~~OW:"J,~~~CURRED_ _ ___ _~~__ _~_~._____ ___
<br />
<br />
<br />221. LOCATION Of INJURV. STREET So NUMBER, APT. NO. CITYITOWN STATE ZIP CODE
<br />
<br />Z
<br />!':!i
<br />,,2
<br />1l~>-
<br />i5.11..J
<br />~ g>~
<br />01"
<br />""C
<br />~~
<br />
<br />2310. DATE Of DEATH (Mo.. D.y, Vr.)
<br />May 29, 2008
<br />23b. DATE SIGNED (Mo., Day, Vr.)
<br />5/30 JcJI:;
<br />
<br />240. DATE SIGNED (Mo.. Day, Vr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />Z
<br />,.,:!i~
<br />"" <.>Z
<br />-II:
<br />!i~~
<br />E .., <( Z
<br />o iI:~ 0
<br />"WZ
<br />OIZ::l
<br />""00
<br />{!. II: tJ
<br />0..
<br /><.>0
<br />
<br />m
<br />
<br />123.. TIME OF DEATH
<br />3:00 A.m
<br />
<br />240. PRONOUNCED DEAD (Mo., Day, Vr.) 24d. TIME PRONOUNCED DEAD
<br />
<br />m
<br />
<br />24e. On the bl!llsls of examination .nd/or Inv.stlgation! In my opinion death OCCUfTed
<br />.t the time, dl!llle and pl8ce and dU8 to the c.use(l) etated. (Signature and Title)
<br />
<br />23d. To lhe be.t of my knowledge, death occurred .t the time. dale and place
<br />and du. 10 1II. c.us.(a) It.led. (Slgn.turo and Tme)
<br />
<br />~
<br />
<br />12Gb. WAS CONSENT GRANTED?
<br />Not Appll.abl. If 2$0 I. NO 0 YES 0 NO
<br />
<br />'p
<br />~~
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 1260. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />o YES )i:'J NO 0 PROBABL V 0 UNKNOWN 0 YES .l8I NO
<br />
<br />27. NAME, TITLE AND ADDRESS OF CERTifiER (PHYSICIAN, CORONER'S PHVSICIAN OR COUNTY ATTORNEV) (Typ. or Prtnt)
<br />Jennifer Brown, M.D., 729 N. Custer Ave. Grand Island,
<br />
<br />
<br />,At,"~A" J. r~:
<br />
<br />V
<br />
<br />NE
<br />
<br />68803
<br />
<br />2Ga. REGISTRAR'S SIGNATURE
<br />
<br />21b. DATI! FILED BV REGISTRAR (Mo.. Day, Vr.)
<br />
<br />JUN 9 2008
<br />
|