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<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL TH:ACi/~#.I.JN..~NSERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA5K!'r' .,' "OF HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR<vtr.'>~~',
<br />'/1-" '10
<br />
<br />
<br />DATE OF ISSUANCE
<br />
<br />NOV 0 6 2008
<br />
<br />200903585
<br />
<br />1. D1,CeDeNrS-NAMe (FI"'I, Middle,
<br />
<br />......':
<br />
<br />Connie Lou Jensen
<br />4. CITY AND STATIO OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Female
<br />5a. AGE-Lal! Blrthd.y 5b. UNDER 1 YEAR 5c. UNDeR 1 DAY 5. DATe OF BIRTH (Mo.. D.y, Yr.)
<br />
<br />(Y",.)
<br />
<br />HOURS MINS.
<br />
<br />MOS. DA Yll
<br />
<br />Sibley, Iowa
<br />7. SOCIAl. seCURITY NUMBeR
<br />
<br />October 27, 1941
<br />
<br />66
<br />
<br />ea. PlAce OF DEATH
<br />~ Iii]lnpoUenl
<br />o ERlOlJlp.U.nl
<br />o DOA
<br />
<br />QIljeB;. 0 NUrllng Home/l TC
<br />o D.c.d.nl'. Home
<br />o Oth'r(Speclfy)
<br />
<br />o Ho.plc, Facility
<br />
<br />506-46-0597
<br />
<br />Ub. FACILITY-NAME (If nOlln.UtuUon. glv. .Ire.land numb.r)
<br />
<br />Saint Francis Medical Center
<br />
<br />8c. CITY OR TOWN OF DEATH (Includ. Zip Cod.)
<br />
<br />Grand Island 68803
<br />
<br />la. ReSIDeNC!;-STATe
<br />
<br />ed. COUNTY OF DEATH
<br />
<br />lb. COUNTY
<br />
<br />
<br />68801
<br />
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<br />
<br />Nebraska
<br />Id. STReeT AND NUMBeR
<br />
<br />Ill. INSIDe CITY LIMITS
<br />~ Y.. 0 No
<br />
<br />Hall
<br />
<br />If. ZIP CODE
<br />
<br />818 W. 12th
<br />
<br />10.. MARITAL STATUS AT TIME OF DEATH 0 M.rrt.d 0 N.v.r M.rrted lOb. NAME OF SPOUSE (FI"," Mlddl., La." Suffix) "wife. give meld.n n.me,
<br />
<br />o M.rrted, bul eeparel.d 0 Widowed iii Dlvorc.d 0 Unknown
<br />
<br />
<br />11. FATHER'S.NAMe (FI",I, Mlddl., LillI, Suffix)
<br />
<br />Mlddl., M.ld.n Sum.m.)
<br />
<br />Lawrence
<br />
<br />Nonneman
<br />
<br />Beachler
<br />
<br />14b. ReLATIONSHIP TO DeceDENT
<br />
<br />13.l<VeR IN U.S. ARMED FORCES? Glv. d.I.. of 1O..lc.lf Y...
<br />
<br />(Y.', No, or Unk.) No
<br />
<br />le. MeTHOD OF DISPOSITION
<br />(XI Surla' 0 Don_lon
<br />o Cremallon 0 ~ntDmbrmmt
<br />
<br />DR....... Oot..~.po.II.J
<br />
<br />Dau hter
<br />
<br />15c. DATE (Mo.. n.y. Yr.)
<br />
<br />October 27,2008
<br />
<br />STATIO
<br />
<br />18b. LICeNS!; NO.
<br />id5? 7
<br />
<br />CITYfTOWN
<br />
<br />Westlawn Memorial Park Cemetery
<br />
<br />17.. FUNERAL HOME NAME AND MA/LING ADDRESS (SI",.I, City or Town, Sill.)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />Nebraska
<br />17b. Zip Cod.
<br />68801
<br />
<br />Grand Island
<br />
<br />CAUSE OF DEATH See Instructions and exam
<br />
<br />
<br />11. PARr I. Enter th. ch./n of .Wlafa' _ diM."', InJurl.., or eompllcaUon.. thBt dlnlctly CBUBI!td th. d.-th. DO NOT .nt., ttlnnlnal ....nt. .uch as c.rdlac:: ........,
<br />....pl,ato.., a.....st, 0' vlntrlcutar nbrtUa1lon wllhout.hl:lwlng thB eUololJY. 00 NOT ABBR!iV1ATE. En., Onlt on. caLlH on a IInl. Add addltlon.1IIn.." n.c:....fY.
<br />
<br />APPROXIMATe INTeRVAL
<br />I on.oIlo d..lh
<br />I
<br />I .:2. uk$'
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl..... or condlllon ",.ulllng
<br />In d..th)
<br />
<br />
<br />on..t to death
<br />I
<br />
<br />I
<br />
<br />.)
<br />
<br />S.quenU.lly 11.1 condllion., If
<br />.ny,I..ding to th. eau..lllted
<br />on IIn. ..
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />~ #
<br />b) 2M ~\
<br />
<br />on'oIlo d..th
<br />I
<br />I 1:3 /"10/11<$
<br />
<br />DUE TO, OR AS A CONSEQUENCe OF:
<br />
<br />Enler Ih. UNDERL YlNG CAuse C)
<br />(dl.e... or Injury Ih.llnlll.led
<br />Ih. evenll ",.ulllng In d..lh) DUE TO, OR AS A CONSEQUENCE OF:
<br />lAST
<br />
<br />onset to d..th
<br />I
<br />I
<br />
<br />dl
<br />
<br />18. PART II. OTHeR SIGNIFICANT CONDITIONS-Condlllon. conlribuUng to Ih. d.ath bul nol r..ulllng In Ih. und.rlylng c.u.. glv.n In PART I.
<br />
<br />18. WAS MEDICAL EXAMINER
<br />OR CORONER CO"TACTeD?
<br />
<br />DYES [3"'"NO
<br />
<br />a:
<br />w
<br />u:
<br />ffi
<br />(.)
<br />;,;,
<br />,g
<br />~
<br />-a
<br />g
<br />(.)
<br />.l!l
<br />o
<br />...
<br />
<br />
<br />21c. WAS AN AUTOPSY peRFORMeD?
<br />Dyes [J,M1'
<br />
<br />~t Cr-'
<br />
<br />21b.IF TRANSPORTATION INJURY
<br />o Drlvor/Operator
<br />o P....ng.r
<br />o P.d.olri.n
<br />o Oth.r (Sp.clfy)
<br />
<br />20. IF EMALE;
<br />~I pr.gn.nl wllhln pa.1 y r
<br />o P",gn.nl 01 11m. of d.alh
<br />o NOI pregn.nt. but p",gnanl within 42 d.y. .f d..th
<br />o Not pregnant, but pregnant 43 day. to 1 y.ar b.fore death
<br />o Unknown If preyn.nl within th. po.1 y.ar
<br />
<br />21a. MANNER OF DEATH
<br />lijMti'fur'l 0 Homlcld.
<br />o Accld.nl 0 P.ndlng Inveellgallon
<br />o Sulcld. 0 Could nol b. delermlned
<br />
<br />21d. WERE AUTOPSY FINDINGS AVA/LABL!;
<br />TO COMPLETE CAUSE OF DEATH?
<br />
<br />Dyes (31l'b
<br />
<br />22a. DATE OF INJURY (Mo., D.y, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PlACE OF INJURY-AI home. f.rm, .1....1, f.clory, omc. building. conelNction .11.. .Ic. (Sp,clfy)
<br />
<br />22d.INJURY AT WORK? n.. DESCRIBE HOW INJURY OCCURR!;D
<br />DYES oNO
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />CITYfTQWN
<br />
<br />~~
<br />Jt-
<br />fa..jj
<br />ag'o
<br />..'6
<br />.<>c
<br />~~
<br />
<br />231. DATE OF DEATH (Mo.. DIy, Yr.)
<br />October 21,
<br />
<br />24a. DATE SIGNED (Mo., Day. Yr.)
<br />
<br />J4b. TIME OF DEATH
<br />
<br />>-~~
<br />.<>OZ
<br />11 iii:!i
<br />jifl=::i
<br />~1Il<Z
<br />o il:t 0
<br />uwi
<br />llZ:J
<br />~~8
<br />0..
<br />00
<br />
<br />
<br />m
<br />
<br />240. PRONOUNCED DEAD (Mo.. D.y, Yr.) 24<1. TIME PRONOUNCED DEAD
<br />
<br />A.m
<br />
<br />m
<br />
<br />248. On the bull of examln.tlon and/or Investigation, In my opinion d..th occu"..d
<br />.1 Ih. lime, d.le and plac. .nd du.lo th. c.u.o(.) .lIlad.(Slgnalur. and TlU.)
<br />
<br />26.. HAS ORGAN OR TiSSUe D~ BEEN CONSIDERED?
<br />o yes ~o
<br />
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typo or Prlnt)
<br />~ian Crouch, D.O., 800 Alpha st~, Grand Island,
<br />
<br />2Ue. REGISTRAR'S SIGNATURE
<br />
<br />28b. WAS CONSENT GRANT!;D?
<br />Not Appllcabl. "2lla Ie NO 0 YES ~
<br />
<br />NE 68801
<br />
<br />
<br />26b. DATE FILED BY ReGISTRAR (Mo., D.y, Yr.)
<br />
<br />NOV 3 2008
<br />
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