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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL TH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA ~t:teNT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY~FOR ~:T~r:'j,.{~~~~.,.,~ ~ .
<br />
<br />DATEOFISSUANCE , ,." -:- ~.:'. ". '.'.
<br />
<br />STA~ 't'C(j~"~""".' ,...,.
<br />02/25/2009 20 0 902 9 2 3 A~~TI STArl REtfISTR,AR1,
<br />OeP~TrJF,idFi#1fH AIVD . ~
<br />LINCOLN, NEBRASKA Hff/J:1~tjI::~tKiSl:E'\ !~. :
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SE~~S ~:< ';-~"'}" .X;.::". ......:;} ;: 09 00392
<br />CERTIFICATE OF DEATH ". . ,~~"".,.,.,; '.'\,c.'~.. ,.
<br />
<br /> ~':~ ..J,~. ,. '. h I ~-)' ':/:~\l~' ',';';._~.
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX..Sr:.... :a:..:AAI~Rf~~(MO., Day, Yr.)
<br /> Connie Marie Carlson Female ..: J /II YFebNa~1{), 2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 bAY' &.DA1'&-OF BIRTH (Mo., Day, Yr.)
<br /> (Yra.) MOS. I DAYS HOURS I MINS.
<br /> Grand Island, Nebraska 60 July 1,1948
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 506-60-6887 ~ ~ Inpatient QIJ::!m 0 Nursing HomelL TC o Hoaplce Facility
<br /> 8b. FACILITY-NAME (If not Institution, give street and number) o ERlOutpatlent o Decedenfs Home
<br />a::
<br />0 Nebraska Heart Hospital DDOA o Other (Specify)
<br />I-
<br />U
<br />W 8c. CITY OR TOWN OF DEATH (Include Zip Code) 18d. COUNTY OF DEATH
<br />a::
<br />is Lincoln 68526 Lancaster
<br />..I 9a. RESIDENCE.sTATE 19b. COUNTY 19c. CITY OR TOWN
<br />~
<br />w Nebraska Hall Grand Island
<br />;z j' APT. NO.
<br />::J 9d. STREET AND NUMBER 191. ZIP CODE 199. INSIDE CITY LIMITS
<br />IL 4117 W Capitol Ave 68803 rn YES 0 NO
<br />;.;,
<br />J:> 10a. MARITAL STATUS AT TIME OF DEATH 1&1 Married 0 Never Married 110b. NAME OF SPOUSE (First, Suffix) If wife, give maiden name
<br />'51 Middle, Last,
<br />I o MarTled, but separated 0 Widowed 0 Divorced 0 Unknown Donald Lee Carlson
<br />11. FATHER'S-NAME (First, Middle, Last, Suffix) 112. MOTHER'S-NAME (First, Middle, Malden Surname)
<br />Ralph Leroy Cook Betty Lou Douglas
<br />Q. 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. 1148. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />0 (Yes, No, or Unk.) No Donald Lee Carlson Husband
<br />u
<br />1: 15. METHOD OF DISPOSITION 16a. EMBALMER.sIGNATURE 116b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />~ 1&1 Burial o Donation Brooke White 1344 February 13, 2009
<br /> o Cremation 0 Entombment 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br /> o Removal o Other (Specify) Clarks Cemetery Clarks Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) l17b. Zip Code
<br /> John A. Gentleman Mortuaries 1010 N. 72nd Omaha Nebraska 68114
<br /> CAUSE OF DEATH (See instructions and exam Dies)
<br /> 18. PART I. Enter tho chain of ovento. -dl..a..., Injurloo, or compllcatlon<<hat dlreC1ly cau..d lho doa1h. 00 NOT onter to"nlnal o.onte ouch a. cardiac arrest, APPROXIMATE INTERVAL
<br /> re.plratory arre.... or ventrteular fibrillation without Ihowlng tlWt '-:iOIOgy. DO NOT ABBREVIATE. Enter onty one cause on :II line. Add addttlonallln..lf rMc:eHafY.
<br /> IMMEDIATE CAUSE: onset to death
<br /> lMlI8IllAftCAll$l! tf'1oIaI a) Cardiovascular Collapse 1 Hour
<br /> dIM.HI or condltton rasuttlng
<br /> In doalh) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> SOquontlally list condhlons, If b)
<br /> ,any, ludlng to the eaueeUsted
<br /> on line ..
<br /> DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Enter tho UNDERLYING CAUSE C)
<br /> (dl..... or Injury that Initiated
<br /> the events resuttlng In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> LAST d)
<br /> 18. PART II. OTHER SIGNIFICANT CONDITIONS-Condltlons contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br />a:: DYES l&I NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b.IF TRANSPORTATION INJURY 2k WAS AN AUTOPSY PERFORMED?
<br />u:
<br />i= I:&l Not pregnant within past year 1&1 N.1tural o Homicide o Ori.or/Operator DYES 1&1 NO
<br />D:: o Pregnant at time of death o Passenger
<br />W o Accldont o Pending Inve"-Iglilltlon
<br />U
<br />i o Not pregnant, but pregnant within 42 days of d81i11th o Suicide o Could not be dotermlnod o Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />o Not pregnant, but pregnant 43 d..y. to 1 year before death o O1hor (Specify) TO COMPLETE CAUSE OF DEATH?
<br />f o Unknown If pregnant within the past year DYES o NO
<br />Q. 22a. DATE OF INJURY (Mo.. Day, Yr.) 122b. TIME OF INJURY I 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (SpeCify)
<br />E
<br />0
<br />u
<br />1: 22d. INJURY AT WORK? r2e. DESCRIBE HOW INJURY OCCURRED
<br />~ DYES ONO
<br /> 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) :~i 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> .:~ February 10, 2009
<br /> i~>- 23b. DATE SIGNED (Mo., Day, Yr.) I 23c. TIME OF DEATH i~L- 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> ... ...J February 23, 2009 08:43 AM
<br /> e 0. z eo.clI!
<br /> 8 ~o 3d. To tho bOlII of my knowlodgo. doath occurred ot tho tlmo. dsto and place 85io 2.... On the b..I. of examination and/or Investluatlon. In my opinion d.ath occurred at
<br /> 11 is and duo to tho cau..tO) stated. (Slgnsture and ThIO) 110:0 the time, date and place and due to the CilUS8(S) stated. (Signature and Title)
<br /> ~ j Steve L. Martin, MD o:i!u
<br /> c 1-8~
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 126a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? II 26b. WAS CONSENT GRANTED?
<br /> DYES 1&1 NO o PROBABLY o UNKNOWN 1&1 YES 0 NO Not Applicable If 26a 10 NO 1&1 YES o NO
<br /> 2T. NAME, TITI,.E AN '1I'IeIilIPHY~Il;IAN, l;OIilON IAN OIill;OUNTY ,.., ., "pe or Print)
<br /> Sieve L. Martin, MD, 7440 S 91s1 St, Lincoln, Nebraska, 68526
<br /> 28a. REGISTRAR'S SIGNATURE~ ~ I 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> "-<-. ....<D~ February 24, 2009
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