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<br />STATE OF NEBRASKA
<br />
<br />~
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL TH AND HUt'/AN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKAPEPARTMEN,T OF-HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL,~6Rb~;/I" i, "
<br />
<br />DATE OF ISSUANCE 200901417 ~:.4~fE~~
<br />
<br />STANLEYS. COOl?Ei{.' .'," . ','.
<br />A. S.S.IStA.NF,~T.. ..,.."A.TER. E"..9I.S.TRAR;
<br />DEP1.R:TM6l!r pt= I;f~A~!...H.AN~;
<br />HI,lf'dArJ. SERVIC1;;$ .'._ :_
<br />'>, \~;.... :Z', ,">:,:-:"' ",'
<br />
<br />, ." (. {j r.... . ""
<br />;. (,~~... 1..... ; 1 i':'. :~',: '.: -"\.~'
<br />
<br />STATE OFNEBRASKA-DEPARTMENTQF HEALTH AND HUMAN SERVICES FINA NCEA~ri~~PPomm',fl. 2. '03' 96
<br />,______._.. CERTIFIC~:rE OF DEATH ' .~ " -' U ';:J'
<br />
<br />JAN 2 6 2009
<br />
<br />200900841
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />
<br />1. DECEDENT'S.NAME (FlrSI,
<br />
<br />Norma
<br />
<br />Middls,
<br />Augusta
<br />
<br />LSSI,
<br />
<br />Lorenzen
<br />
<br />Suffi,)
<br />
<br />2, SEX
<br />emale
<br />
<br />3, DATE OF DEATH (Mo" Day, Yr,)
<br />January 13,2009
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE.Laat Birthday
<br />(Yrs)
<br />
<br />87
<br />
<br />
<br />5c. UNDER 1 DAY 6. DATE OF BIRTH (MO., Day, Yr.)
<br />MINS.
<br />
<br />Worms, Nebraska
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />529-16-4462
<br />
<br />January 28. 1921
<br />
<br />60. PLACE OF DEATH
<br />llil.Sfl1Al.:
<br />
<br />o Inpatient
<br />
<br />QIl:fB: 0 Nursing HomelLTC [) Hospice Facilily
<br />
<br />6b. FACILITY.NAME (II nol Instltullon, give Weel end number)
<br />
<br />Xl ERIOulpalianl
<br />
<br />o Decedent'. Home
<br />
<br />St. Francis Medical Center
<br />
<br />OOCl\
<br />
<br />o other (Specify)
<br />
<br />8d. COUNTY OF DEATH
<br />Hall
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />
<br />90, R~SID~NC~.STAT~
<br />Nebraska
<br />
<br />9b. coumY
<br />Hall
<br />
<br />
<br />9d. STREET AND NUMBER 91. liP CODE
<br />4150 W. Capitol Ave. 68803
<br />100, MARITAL STATUS ATTIME OF DEATH (llMorried [) Never Married lOb. NAME OF SPOUSE (FirSI, Middle, Last, Sulflx) It wife, give maiden name.
<br />
<br />9g. INSIDE CITY LIMITS
<br />Xl YES 0 NO
<br />
<br />o Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Max Lorenzen
<br />
<br />11. FATHER'S,NAME (Firsl.
<br />Henry
<br />13. EVER IN U.S. ARMED FORCES' Give dale. of .ervlcelf ye.. 14a.INFORMANT.NAME
<br />(Ye., no, or unk.) No
<br />-...-. . .._-_.._...~.."'-"-
<br />15. METHOD OF DISPOSITION
<br />
<br />Middle,
<br />
<br />Last!
<br />
<br />Suffix)
<br />
<br />12, MOTHER'S.NAME (First,
<br />
<br />Meta
<br />
<br />MiddlS,
<br />
<br />Malden Surn.ms)
<br />...... _~~~~er~_.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />16c. DATE (Mo" Day, Yr, )
<br />anuary 13. 2009
<br />STATE
<br />
<br />QlJurial
<br />
<br />o Donation
<br />
<br />
<br />16b, LICENSE NO,
<br />1191
<br />
<br />o Cremation 0 Entombment
<br />
<br />CITY /TOWN
<br />
<br />o Removal 0 Olher (Specity)
<br />_~_______m,"__._ '!'liE!.8ert Cemetl:!EY.:
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Streel, Clly or Town, Slate)
<br />
<br />Livingston-Sondermann F.H. 601 N.Webb
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />17b. Zip Code
<br />68803
<br />
<br />Road Grand Island. Nebraska
<br />
<br />,t8. PART I. Enler the chaIn 01 evenls--dlseases, injuries, or complications--Ihal directly caused the dealh, DO NOT enter terminal events such as cardiac a.rraSI,
<br />raspiratory arrest. or ventricular fibrillallon without showing the etiology. DO NOT ABBREVIATE, Enter only one cause On a line. Add additional lines If necessary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE (Flnot
<br />dlHlM or condition multlng
<br />In death)
<br />
<br />11' IMMEDIATE CAUSE:
<br />W natural causes associated with old age
<br />
<br />I
<br />I
<br />
<br />I ~n.et to doalh
<br />I
<br />I unknown
<br />
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />onsollo deslh
<br />
<br />Saquanllalty tI.l condition., If (b)
<br />.ny, loading 10 tho tau.. tI.lsd --DUETO OR AS A CONSEOUENCE OF'
<br />~"M~ ' .
<br />Entorthe UNDfR~YING CAUSE
<br />(dl..... or Injury th.t Inlll.lld
<br />lhe o_ls ....uitlng in deeth)
<br />LAST
<br />
<br />on.ello dealh
<br />
<br />(C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on.ello dealh
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS.Conditlons oonlributlng 10 Ihe death but nol re.ulting in Ihe underlying cause given in PART I,
<br />
<br />18. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />!t YES ~O
<br />
<br />~21t. IF FEMALE:
<br />!XI Not pregnant within past year
<br />o Pregnant at time of death
<br />[) NOI pregnanl, bul pregnsnl within 42 dsys 01 deolh
<br />o Nol pregnant. but pregnant 43 days to 1 year before death
<br />o Unknown II pregnant within the past year
<br />
<br />'i1a. MANNER OF DEATH
<br />[m Natural 0 Homicide
<br />
<br />21 b, IF TRANSPORTATION INJURY 1:!c. WAS AN AUTOPSY PERFORM EO?
<br />o Driver/Operator
<br />
<br />o AccidenlO Psnding Investigation
<br />o Suicide 0 Could not be determined
<br />
<br />o Passenger
<br />o Pedestrian
<br />U Other (Specily)
<br />
<br />o YES
<br />
<br />lSl NO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF D~ATH?
<br />o YES ~NO
<br />
<br />[) YES 0 NO
<br />
<br />
<br />m
<br />
<br />220. DAT~ OF iNJURY (Mo., Day, Yr,)
<br />
<br />22b. TIME OF INJURY 22c, PLACE OF INJURY.AI home, tarm, .treel, faclory, office building, construClion .ile, elc. (Speclty)
<br />
<br />22d, INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO,
<br />
<br />crrvrrowN
<br />
<br />5lJ'JE
<br />
<br />ZIP CODE
<br />
<br />23b, DATE SIGNED (Mo" Day, Yr,)
<br />
<br />23c. TIME OF DEATH
<br />
<br />
<br />m
<br />
<br />..:'i~
<br />"g~
<br />{..o
<br />i!:S~
<br />!l'''~15
<br />.."'z
<br />,d=>
<br />~1i:8
<br />8a
<br />
<br />1!D, TIME OF DEATH
<br />5:15
<br />
<br />am
<br />
<br />23.. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />am
<br />
<br />23d. To lhe beGI 01 my knowledge, death occurred at the time. date and place
<br />and due to Ih~ cause(s) Slated. (Signature and Title) T
<br />
<br />5. DID TOBACCO USE CONTRIBUTETOTHE DEATH'
<br />
<br />[) YES 0 NO 0 PROBABLY Q( UNKNOWN 0 YES I2i NO Nol ApplicaDle 1126e ie NO 0 YES ONO
<br />~?j'IAM'E:'TITi:E'ANDADORESSOF CERTIFIER (PHYSICIAN. CORONER'S PHYSICIAN OR COUNTy-mORNEY)'(Type;,'P,in,i
<br />Jack Zitterkopf. Chief Deputy Hall County Attorney, 231 S. Locust Street. Grand Island, NE 68801
<br />
<br />28e. REGISTRAR'S SIGNATURE 28b, DATE FILED BY REGISTRAR (Mo., D.y, Yr.)
<br />JAN J 2 2009
<br />
<br />
<br />HHS.6111/03 (55061)
<br />
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