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<br />~
<br />
<br />STATE OF NEBRASKA
<br />
<br />~
<br />
<br />WHEN THIS COpy CARRIES THE RAISEO SEAL OF THE NEBRASKA OEPARTMENT OF HEAL TH ,,4NIJ/;fVMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA:(!~PEflff.R.T}ytEIllr; O. F HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOP: V~ll'1'i 'SE.CdktfS.:.' ~ J
<br />
<br />DATE OF ISSUANCE ~rlfQ~~
<br />: ~~~'EY s: Cb()PBR:);.';"~~~>'.. ':.
<br />DEe 05 2008 , ~$lS'lf4rrr:$Tl'>TE1<EGISTRAI1
<br />2 0 0 81 0 2 4 2; ,*PAIf:~~T lJ#lfItAi. TIjt ~Nt)
<br />LINCOLN, NEBRASKA . , fWti4ANSERVlf;ES ;. (~; ~.'
<br />~ ~\:.. .~I(-~, '; "~;'"~~'~'~'(''::'~~~(,',>:'/~''' ~~:~ ~'
<br />I( ...SRt'\'~/\,,,':\l\ ....'
<br />) ,f'/, ............ ";'. -
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANC~'A~.~UPpQ".."8" ~ 18 4 0
<br />CERTIFICATE OF DEATH "', .. ~'." U.'~ v
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE.Lasl Birthday 5b. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />71
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />3. DATE OF DEATH (Mo.. Dsy, Yr.)
<br />October 20, 2008
<br />
<br />6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />
<br />1. DECEDENT'S.NAME (First,
<br />Henry
<br />
<br />Mlddla,
<br />Adrian
<br />
<br />Last,
<br />Visser
<br />
<br />Sulll.)
<br />
<br />2. SEX
<br />Male
<br />
<br />August 30, 1937
<br />
<br />8a. PLACE OF DEATH
<br />
<br />531-36-6717
<br />
<br />liO.SfIIAL.
<br />
<br />a Inpallant
<br />
<br />QlliE8: a Nur.ing Hom./LTC a Ho.plc. Facility
<br />
<br />FACILITY.NAME (If not Institution, glvo slroot ond numb.r)
<br />
<br />iI ERlOutpationt
<br />
<br />a D.c.danl'. Hom.
<br />
<br />St. Francis Medical Center
<br />
<br />a 000. a Other (SpeCify)
<br />8c. CITY OR TOWN OF DEATH (Includ. Zip Ccda) 8d.COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />9a. RESIOENCE-STATE ~ 90. COUNTY
<br />Nebraska ~ Hall
<br />
<br />10.. MARITAL STATUS AT TIME OF DEATH IXI Marriod a N.v.r Marrl.d lOb. NAME OF SPOUSE (First. Mlddl., LaSl, Suffl.) II wlf., glv. mald.n nam..
<br />
<br />
<br />g,- ZIP CODE
<br />
<br />9d. STREET AND NUMBER
<br />301 South Alexandria
<br />
<br />68824
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />Xl YES a NO
<br />
<br />a Marri.d, bul..p.r.l.d UWldowad a Dlvorc.d a Unknown Carolyn Hawk
<br />
<br />11. FATHER'S-NAME (First,
<br />Chris
<br />
<br />Middl.,
<br />
<br />La.t,
<br />Visser
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S.NAME (First,
<br />Marie
<br />
<br />Mlddl.,
<br />
<br />Mald.n Surnam.)
<br />Molendyk
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Wife
<br />
<br />13. EVER IN U.S. ARMED FORCES? Glv. dat.a of '.Nlc.1I y... 14..INFORMANT.NAME
<br />XS,~J.or.nl},/27 /1959 4/27/1962 Carolyn Visser
<br />
<br />15 ~::~: OF DI~::~::I:~ 16.. EMBAL~~-~GN~;~almed ~I '6b~L;CENSeNO
<br />
<br />~Cramation a Entombm.nl 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN
<br />
<br />16c. DATE (Mo.. Day, Yr. )
<br />October 21, 2008
<br />
<br />STATE
<br />
<br />a Ramov.1 a Oth.r (Sp.clly)
<br />
<br />Butherus-Maser-Love Crematory
<br />
<br />Lincoln, Nebraska
<br />
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Str..I, Clly or Town, Stat.)
<br />Apfel Funeral Home, 1123 West Second,
<br />
<br />r..plr.lory .rr..t, or v.ntrlcul.r flbrlll.tion without .howlng th. .tlology. DO NOT ABBREVIATE. Ent.r only on. D..'. on .Iln.. Add .ddilion.llin..1I n.c....ry.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />Myocardial Infarction
<br />(a) l?eRill.W) 'Ibxioolory.' r. i\K-thor St'1:laiC::J
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to delith
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />d1_orcondltlonreeultlng
<br />In"")
<br />
<br />Hours
<br />on..tto d.ath
<br />
<br />Sequ.ntlally 1111 condition" II
<br />.ny, loading 10 Ih. ceu..111Ied
<br />on line 8.
<br />En\et' the UNDERlYING CAUSE
<br />(dl...... or Injury Ihallnlllated
<br />lhe event.s reeulllngln doolh)
<br />lASr
<br />
<br />~) Occlusive Arteriosclerotic Heart Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Years
<br />
<br />ons.t 10 da.th
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />20. IF FEMALE.
<br />a Not prsgn.nt wllhln pa.t ya.r
<br />a pr.gnant at tlm. of d.ath
<br />a Not pr.gn.nt, but p,.gnent wllhln 42 d.y. of d.ath
<br />o Not pregnant, but pregnant 43 days to 1 year before death
<br />a Unknown ilpr.gnant within the p.'1 y..r
<br />
<br />21a. MANNER OF DEATH
<br />II Natural a Homlcid.
<br />
<br />a Accid.metwrming Inv..tig.tion
<br />
<br />a Suicide a Could not ba d.t.rmln.d
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />a Drlv.r/Operator
<br />
<br />a P....ng.r
<br />
<br />a Pad..t,l.n
<br />
<br />a Oth.r (Spacify)
<br />
<br />t 9. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />iXYES a NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS.Condllion. contributing to the d..th but not ra.ulting In the undarlying cau.. givan in PART I.
<br />
<br />aI YES a NO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />}EI YES a NO
<br />
<br />a YES a NO
<br />
<br />
<br />22.. DATE OF INJURY (Mo., D.y, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY.At hom., farm, str..t, faClo,y, olllc. building, con.tructlon .it., .tc. (Sp.cify)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />ClTYiTOWN
<br />
<br />STArE
<br />
<br />ZIP CODE
<br />
<br />23.. DATE OF DEATH (Mo.. Day, Y'.)
<br />
<br />24;. ~A~Et~G~~d'8$Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />ApprOx 7: 00 AMI
<br />
<br />m
<br />
<br />~~~
<br />I~'"
<br />~i5~
<br />E ...~~
<br />g"'z
<br />.xlllii!
<br />~~~
<br />815
<br />
<br />24c. PRONOUNCED DEAD (Mo., D.y, Yr.)
<br />10-20-2008
<br />
<br />24d. TIME PRONOUNCED DEAD
<br />A ox 7:00 AM1
<br />
<br />23b. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />230. TIME OF DEATH
<br />
<br />23d. To fh. b..t 01 my knowl.dg., d..lh occurr.d at the tlm., d.t. and pl.ce
<br />and du.lo the c.u..(.) stated. (Slgn.tur. and Titl.) ,.
<br />
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />o YES .. !I NO a PROBABLY a UNKNOWN.. a YES ~NO
<br />27. NAME, TITLE"AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. or Print)
<br />Matthias 1. Okoye, M.D., J.D. 600 Sout 70th Street Lincoln NE
<br />
<br />68510
<br />
<br />28.. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />
<br />NOV 2 6 2008
<br />
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