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<br />STATE OF NEBRASKA
<br />
<br />~
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANE5HUMAN SERVICES, ITCERTIFIES
<br />THE BELOW TO BE,A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA,pEpmr.rETV':;; OF-HEALTH AND
<br />HUMAN SERVIC~S, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR ~,f~L\~~~~~,:~,~ ~ l'
<br />
<br />DATE OF ISSUANCE b~lif E"~.
<br />"st;~i~~PC~~ER' ".: '/
<br />JAN 2 6 2009 200 90 0 8 .t 1 A$5;stAN[-~$tATE REGI$TRAR'
<br />.. DEP.1R:rM~ Pi; J/EtE,.tcA~~'.:' i
<br />HVfdAN SER.vfCtS.", :_'
<br />:< ~~\. .1,,->~):';j~";\.: . . . :(_~:)
<br />'. (' ,'-l:{)j")! c..-,," .
<br />, '$ S>.....:........> ,"I," ,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCEANIi ltUPPQ1TY,'hlV 2....0. 79 6
<br />CERTIFICATE OF DEATH . ~ '( .',U '::;J' -. ,J
<br />
<br />/.:,
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />
<br />1. DECEDENT'S-NAME (First.
<br />
<br />Norma
<br />
<br />Middle, LeO!,
<br />Augus~'!."."."_ Lorenzen
<br />
<br />Suffix)
<br />
<br />2. S~X
<br />emale
<br />
<br />3, DATE OF DEATH (Mo.. Dey, Yr.)
<br />u. _~~nuary 13,2009
<br />
<br />6. OATE OF BIRTH (Mo.. Day. Yr.)
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a. AGE-Last Birthday
<br />(Yrs.)
<br />
<br />87
<br />
<br />
<br />January 28, 1921
<br />
<br />Worms, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />529-16-4462
<br />
<br />Ba. PLACE OF DEATH
<br />1iQ.SfJIAJ.: Q Inpatianl
<br />
<br />~ 0 Nursing Homa/LTC 0 Hospica Faclllly
<br />
<br />ab. FACILITY-NAME (It not Institution, give slreet and number)
<br />
<br />Xl ER/Outpati.nl
<br />
<br />Q D.c.d.nf. Hom.
<br />
<br />St. Francis Medical Center
<br />
<br />o lX)\ 0 Other (Spocify)
<br />
<br />ad. COUNTY OF DEATH
<br />Hall
<br />
<br />.c. CITY OR TOWN OF DEATH (Inciud. Zip Cod.)
<br />Grand Island 68801
<br />
<br />!lb. COUNTY
<br />Hall
<br />
<br />
<br />9d. STREET AND NUMBER 9t. ZIP CODE
<br />4150 W. Capitol Ave. 68803
<br />lOa. MARITAL STATUS AT TIME OF DEATH (l[ Marriad Q N.".r M.rrl.d 1 Db, NAME OF SPOUSE (First, Middle, Lasl, Sufllx) If 1011., gl". mald.n nam.,
<br />
<br />9g, INSIDE CITY LIMITS
<br />Xl YES 0 NO
<br />
<br />Q Marrl.d, buts.psrsl.d 0 Widowed 0 Divorcad 0 Unknown
<br />
<br />Max Lorenzen
<br />
<br />1 I, FATHER'S-NAME (First, Middle, Last,
<br />
<br />".".______.___1J:_enry Meyer
<br />
<br />13, EVER IN U.S, ARMED FORCES? (JIve dale, 01 'ervlcelf Y.'. 14a.INFORMANT-NAME
<br />
<br />(Ye"no,orunk.) No Callihan
<br />
<br />Sultix)
<br />
<br />12. MOTHER'S-NAME (Flrsl,
<br />Meta
<br />
<br />15. M~THOD OF DISPOSITION
<br />Qi!urlal 0 Donation
<br />o Cremation 0 Enlombment
<br />
<br />CITY / TOWN
<br />
<br />Middle, Mald.n Surnam.)
<br />Wiegert
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />I ac. DATE (Mo" D.y, Yr. )
<br />anuary 13, 2009
<br />STATE
<br />
<br />o R.moval 0 Other (Spacify)
<br />
<br />
<br />lab. LICENSE NO.
<br />1191
<br />
<br />Wiegert Cemeter
<br />17a. FUNERAL HOM~ NAME AND MAILING ADDRESS (S".sl, Clly or Town, Stata)
<br />Livingston-Sondermann F.R. 601 N.Webb Road Grand Island. Nebraska
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />
<br />17b. Zip Cod.
<br />68803
<br />
<br />PART I. Enter the chain 01 evenls--dlseases, Injuries, Or cornplica1ions~.thal directly causad the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest. or ventricular Ilbrlllation without showing the etiology. DO NOT ABBREVIATE. Enter only one causa on a line. Add additional lines If necessary,
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMM~DIATE CAUSE (Final
<br />dl..... o.condltlon r..ublng
<br />In_)
<br />
<br />'I' IMMEDIATE CAUSE,
<br />W natural causes associated with old age
<br />
<br />I
<br />I
<br />
<br />'1\n,.llo dealh
<br />,
<br />
<br />I unknown
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />Sequ.nll.Uy u.t condlllon.,It
<br />.ny,leedlng 10 the caU'.U.1ed
<br />onlln...
<br />e_the UNDERLYING CAUSE
<br />(dl..... o. Injury thot Inlll.ted
<br />IhOll_la ,"ulllng In de.th)
<br />LASr
<br />
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on..tlo d.sln
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on..llo d.alh
<br />
<br />(d)
<br />~. PART II. OTHER SIGNIFICANT CONDITIONS-Condillon. conlrlbuti~Q ;;"i;;~-d;;'lh bul nol re,ulling In the underlying caus. glv.n in PART I.
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />!l YES ~O
<br />
<br />1(20, IF FEMALE:
<br />II Not pregnant within past year
<br />o Pregnant at timB of death
<br />Q NOI pr.gn.nl, bUI pr.gn.nt Within 42 d.y' 01 d.ath
<br />o Nol pregnant, but pregnant 43 days to 1 year before death
<br />o Unknown II pregnant within the pas! year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />Q Accld.nlO P.nding Investigalion
<br />
<br />21 b.IF TRANSPORTATION INJURY 'ltc. WAS AN AUTOPSY PERFORMED?
<br />Q Driv.r/Op.rator
<br />
<br />Q P....ng.r
<br />
<br />o Pedestrian
<br />
<br />Q YES
<br />
<br />lSl NO
<br />
<br />'1'1.. MANNER OF DEATH
<br />.II Natural 0 Homicide
<br />
<br />CJ SuiCide 0 Could not be determlnad
<br />
<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />Q Olh.r (Sp.City)
<br />
<br />COMPLETE CAUSE OF DEATH?
<br />o YES ~NO
<br />
<br />DYES 0 NO
<br />
<br />
<br />220. PLACE OF INJURY-At home, farm, street, factory, oflice building, construction sitel etc. (Specify)
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYIfQWN
<br />
<br />SWE
<br />
<br />ZIP CODE
<br />
<br />23b, DATE SIGNED (Mo" D.y, Yr,)
<br />
<br />23c. TIME OF DEATH
<br />
<br />
<br />4d, TIME PRONOUNCED DEAD
<br />
<br />m
<br />
<br />..~ 1U
<br />J:l~'"
<br />h~~
<br />UI~
<br />"'0
<br />"Is
<br />
<br />'t!b. TIME OF DEATH
<br />5: 15 am
<br />
<br />23.. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />5:15
<br />
<br />am
<br />
<br />23d. To the best of my knowledge, death occurred al the time. date and place
<br />and dU.lo Ih. cau..(.) 5Isl.d. (Slgnalur. and Till.) '"
<br />
<br />5. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />DYES 0 NO 0 PROBABLY [j( UNKNOWN 0 YES at NO NOI Appllcabl." 26al5 NO Q YES QNO
<br />"'7, NAME, TlTLE-ANii"Aoi:;FlESS'O(CERflFiERIPHYSIcIAN, Co-FlONeR'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. Or Prinl)
<br />Jack Zitterkopf, Chief Deputy Hall County Attorney, 231 S. Locust Street, Grand Island, NE 68801
<br />
<br />29a. REGISTRAR'S SIGNATURE 2ab. DATE FILED BY REGISTRAR (Mo., Day, Yr,j
<br />JAN J 2 2009
<br />
<br />
<br />HHS.6111/03 (55061)
<br />
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