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<br />STATE OF NEBRASKA
<br />
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OFHEA'tTHA/y"CJ. hitJMAtV,.SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH T"H,' eN,E,'SRASKAbifARi,TfY/El'frW,HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSIitJ'RYFOR 't!:rA~ ~?~~~.: /'. ~./,,(l.~ ~ I
<br />
<br />DATE OF ISSUANCE ..,~iJl.~\
<br />
<br />NOV 1 3 2008 200902633 ," ; ~\:;~r:::$~~~E~STRA~I,,\ 'l,
<br />DtJ'fJt{;.t"ME~ (jri..!-iEMtfJ AND;" ;~
<br />LINCOLN, NEBRASKA Hfll':li'Jlr.sERVICJES," :' ,~ .~
<br />". I 0', ;,~.", "'/t ".: f;'l ,J
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN s~R4f.E, \<" .~~ 0 r~, ~~:2.il ~"
<br />I : VI' ~..,',O+~~
<br />
<br />1.DECEDENrs.NAME (Flm. Mlddl., L..t Suffix) 2. SU 3. Of T ( %l!Iy,Vf'l.
<br />'"'l'l;. " ',' ..... ....":.:... ,
<br />Patricia Ann Petersen Female November'3, 2008
<br />
<br />... CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5e. AGE-Leel Birthday lib. UNDER 1 YEAR Be. UNDER 1 DAve. DATE OF BIRTH (Mo., Day, Vr.) I
<br />(Vrs.) MOl. DAVS HOURS IIIINS,
<br />
<br />
<br />St. Paul, Nebraska
<br />7.. SO<?IA~ SECURITY NUMBER
<br />506-66-58"2
<br />
<br />57
<br />
<br />8a. PLACE OF DEATH
<br />
<br />~ I&Ilnpeti.nl
<br />
<br />_1;;1 ERIOutpaU.nl
<br />
<br />OOOA
<br />
<br />November 25, 1950
<br />
<br />Saint Fran is Medical Center
<br />
<br />QJl1iB,;. 0 Nursing HorneIL TC
<br />o llecedenr. HOIIM
<br />d 0thM(sP8cJry)
<br />
<br />o Hotplo. F..,IIlty
<br />
<br />- 2b..-EA.C'J.l1Y-/!!AME. (If llllI Jr-tIlM!on, !/lvJt-'!'ffl!l! .n!!..!l.!!~~1j
<br />
<br />eii. CITY OR TOWN OF DEATH (Inolud. Zip Cod.) 8<1. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />ea. RESIDENCE-8TATE lib. COUNTY
<br />
<br />9f. ZiP CODE
<br />68801
<br />o NIVer M_eeI lOb. NAME OF SPOU$E (First Mlddl., Lal, Suntx) If wlfa, glv. IIIIllden n_.
<br />o Unknown
<br />
<br />
<br />9g. INSIDE CITY LIMITS
<br />o Vaa iii No
<br />
<br />j
<br />i
<br />i
<br />1
<br />E
<br /><3
<br />.z
<br />~
<br />
<br />Nebraska
<br />Ill. STREET AND NUMBER
<br />3532 Farmstead Road
<br />1o...IIIARlTAL STATUS AT TIME OF DEATH IiII11_ad
<br />o Mamad, but _ralad 0 WIdowed 0 DIvorced
<br />
<br />Hall
<br />
<br />Muller
<br />
<br />
<br />12. MOTHER'S.NAME (FIrst Mlddl., M.ld.n SUmallM)
<br />
<br />11. FATHER'S-NAME (First Mlddl., Laet Suntx)
<br />
<br />John
<br />
<br />Darline
<br />
<br />Klin insmlth
<br />
<br />CITYfTOWN
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Husband
<br />
<br />lBe. DATE (Mo., Day, Vr.)
<br />
<br />November 4, 2008
<br />
<br />STATE
<br />
<br />13. EVER IN U.S. ARMED FORCES? Glv. dal.. of oem.. If v... 141. INFORMANT -NAME
<br />
<br />Warren Petersen
<br />181. EMBAUIER.$IGNATURE
<br />
<br />Not Embalmed
<br />
<br />18d. CEMETERV. CREMATORY OR OTHER LOCATION
<br />
<br />Central Nebraska Cremation
<br />
<br />H.. FUNERAL HOME NAME AI\Ill MAILING ADDRESS (SI"",,, City or Town, Slale)
<br />Jacobsen-Greenway Funeral Home, 4110 Street, PO Box 112, St. Paul, Nebraska
<br />
<br />(v.., No, or Unk.) No
<br />18. METHOD OF DISPOSITION
<br />~rtol DOonotlon
<br />[iiI C..mallon 0 EntombOlont
<br />o Romo..' 0 OthnqO""CIfyI
<br />
<br />leb. LICENSE NO.
<br />
<br />Gibbon
<br />
<br />Nebraska
<br />Hb. Zip Cod.
<br />68873
<br />
<br />CAUSE OF DEATH (See Instructions and examples)
<br />
<br />11. ItART L - en....... InjuMli. or complludons- ttw: dnctty cauted the dnth. DO NOT enter tMmlnll.vera .uch as cardIIc: ~
<br />Iftplrmoryamnt, Of v.ntrIc;:u.... flbrlllauon wttnout showlna the "olop_ DO NOT A88REY1ATE. Enter only Qne I:tIUM on a 11M. Add addtltoNlI Unu " necet4IIIry.
<br />
<br />IIIIIIIEDIATE CA SE:
<br />
<br />
<br />>r ~,' I \.t r-<-
<br />
<br />i APl'ROXlMAUINTem'AL
<br />! <JIIHt to d~ath
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />dl..... or candlllon reeulUng .)
<br />In d.alh)
<br />
<br />SequenUally 1101 candlllon., If b)
<br />.ny, I..dlng 10 Ih. c.uoell.led
<br />on IIn. ..
<br />
<br />}U9hDJ,~
<br />
<br /><.. I r I' PI O~ ) J
<br />
<br />Ion... to d..th
<br />
<br />
<br />
<br />I on... to daath
<br />
<br />
<br />
<br />i on." to d..th
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Enter the UNDERLYING CAUSE 0)
<br />(dl..... or Injury thlllnlUa""
<br />th. even"'....uIUng In d..lh) DUE TO, OR AS A CONSEQUENCE OF;
<br />LAST
<br />
<br />d)
<br />
<br />19. PART II. OTHER SIGNIFICANT CONDITlONll.condlllona contrlbullng to the deelh bul notreaulUng In th. underlying ....... g1van In PART I.
<br />
<br />ft Gv\~ ~ V\ ~ l [:or ; 'lA r-e
<br />
<br />18. WAS MEDlCA1. EXAMINER
<br />OR CORONER CONTACTED?
<br />o Yl!$ )ij NO
<br />
<br />It:
<br />W
<br />~
<br />~
<br />j
<br />I
<br />~
<br />dl
<br />{J.
<br />
<br />.!:J' IF FEMALE:
<br />~Not prsgn.nl within p..1 year
<br />o Pregnenl at Um. of d.ath
<br />o Not pregnant bul prsgnanl within 42 day. of deelh
<br />o Nol pregnan~ bul prsgn.nt43 d.ye to 1 ye.r before death
<br />DUnknown If pregnenl within th. """I y.ar
<br />
<br />21a. MANNER OF DEATH
<br />!1 Nalurel 0 HomIcld.
<br />o Aocldenl 0 Pending Inv..llgallon
<br />o Sulold. 0 Could not be d._neel
<br />
<br />21b.IF TRANSPORTATION INJURV
<br />o DflverlOpenltor
<br />o P....ng.r
<br />o PeeI_trl.n
<br />o Other (Spaolfy)
<br />
<br />21c. WAS AN AUTO.,V PERFORMED?
<br />
<br />DYES ,DNO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />
<br />DYES Oi( NO
<br />
<br />22lL DATE OF INJURV (Mo., Dey, Vr.)
<br />
<br />
<br />22b. TIME OF INJURY 220. PLACE OF INJURV-AI hOIlM, farm, ........ faototy, _ building, oon.,",oUon $Ita, .10. (Spaolfy)
<br />
<br />22d. INJURV AT WORK?
<br />DYES ONO
<br />
<br />Uf. LOCATION OF INJURV , STREET & NUMBER, APT. NO.
<br />
<br />CITYfTOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />
<br />241. DATE SIGNED (Mo.. Day, Vr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />",~ru
<br />.a !.! is!!
<br />li5~
<br />~~r:i5
<br />.! Z~
<br />000
<br />... ll:: t)
<br />815
<br />
<br />m
<br />
<br />24<:. PRONOUNCED DEAD (Mo., Day, Vr.) 24<1. TIME PRONOUNCED DEAD
<br />
<br />m
<br />
<br />241. On the baal. of ....mlnallon and/Dt 'nvttUgallon, In my opinion dallth DCou......d
<br />at the 1I11M, data and pi..,. and du.lo the cwee(.)'IIIad. (Slgnalure and TIlle)
<br />
<br />281. HAS ORGAN OR n&SU DONATION BEEN CONIlIDERED?
<br />o YES NO
<br />
<br />29b. WAS CONSENT GRANTED? .
<br />Not Appllc.bl. If 281 I. NO 0 YEs)Q NO
<br />
<br />p
<br />
<br />NOV 1 J 2008
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