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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTl-1.4N~ HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA, DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY F~~2r 13"~:~ILy'ITEtL' ~JS.
<br />DATE OF ISSUANCE ~ . '- ° ~
<br />R •.
<br />nn • "';W 'STA%WY S. C•O,~p~, ;~*, "r',
<br />NQV V 6 ZOOS ~ U ~ Q 0 1,5 ~ ~ , ~ QEP~ST MINT dF..~J~4~~J~ AI'VAD
<br />LINCOLN, NEBRASKA =HUM~RIlxC~S~ "`,~~ ' ~
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAfd~2RVICE~, / ,• T ti Q 1 ~' ~"('~
<br />CERTIFICATE OF DEATW • ~ `r~ •. y^s ' ~? J
<br />
<br /> 1. DECEDENT'S-NAME (First, Middle, Laat, Suffix) ,BFat%~~ ~., ". Fbt~ .,Dry,Yr.)
<br />.~q @'
<br /> 6
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<br />`~~ •„
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<br /> Connie Lou Jensen Fe
<br />n I
<br />~ iiob~
<br />21-
<br />~t008
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 6e. AOE-Last Birthday eb. UNDER 1 YEAR 5c. UNDE MA14`k, ~~,, f~AT,E G6~BIRTH (Mo., Day, YrJ
<br /> (Yro.) MOS. DAYS HOURS MINE.
<br /> Sibley, Iowa 68 Octpbpr 27,' 1941
<br /> 7. BOCIAL SECURITY NUMBER ~• 8a. PLACE pP DEATH
<br /> $O6-~t6-OFJJ'~ HOSPITAL: ®Inpaflanl Q~g;^ Nurainq HomaILTC ^ Hospice Facility
<br /> Bb. FACILITY-NAME (If not Inetitutlon, glvr etretn and number) ^ ER/Outpatisnt ^ Decedent's Homs
<br /> ^ DOA ^ Othar(SpacNy)
<br /> Saint Francis Medical Center
<br /> ec. CITY OR TOWN OF DEATH (Include Zip Cade) Bd. COUNTY OF DEATH
<br /> Grand Island 68803 Hall
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<br />7 Ba. RESIDENCESTATE Bb, COUNTY 9c. CITY OR TOWN
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<br />Nebraska
<br />Hall
<br />Grand Island
<br />
<br />.~ 9d, STREET AND NUMBER Ba. APT. NO. 1N. ZIP CODE 9g. INSIDE CITY LIMITS
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<br />81$ W, 12th
<br />68$01
<br />®Yae ^ No
<br />m 70a. MARITAL STATUS AT TIME OF gEATH ^ Mardad ^ Nsvar Married lab. NAME pF SPOUSE (Flrot, Middlr, Last, SuHlx) H wife, giw maiden name.
<br /> ©Mrrrtad, but separated ^ Widowed ®Dlvomad ~ Unknown
<br />
<br />Q 11. FATHER'S-NAME (Firot, Middle, Laat, SuMix) 12. MOTHER'S-NAME (Firs4 Middle, Malden Sumama)
<br />~ Lawrence Nonneman Ela ne Beachler
<br />@
<br />m 11. EVER IN U.B. ARMED FORCES7 OWe dates of service I} Yea. 74a. INFORMANT-NAME f 144. RELATIONSHIP TO DECEDENT
<br />~ (Yes, No, or Unk.) rip Tricia Shoemaker bau hter
<br /> 18. METHOD OF DISPOSITION 18 hI~IERaIGN UR ~ ~ 7$b. LICENSE Np. 18c. DATE (Mo., Day, Yr.)
<br /> ®eadal ^oonauen LL-~ ~~. ~,,, ~ ~~~~ /`~`~ % October 27, 2008
<br /> ^Cmmaavn ^RMomhmem
<br /> QRemovu ~otneryspeciry)
<br />18d. EMETERY, CREMATORY bR OTH R LOCATION CITYITOWN STATE
<br /> Westlawn Memorial Park Cemetery Grand Island Nebraska
<br /> fla. FUNERAL HOME NAME AND MAILING ADDRESS (Strose, Clty ar Town, State) 17b. Zlp Coda
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> CAUSE OF DEATH See instructions and exam lee
<br /> 16 PART I. Enhr the enam o1 ewnb . diaaaaea, in)urMe, w camplluaane-that dlrecly ceuwd the seam. Do NoT amar Nmlinal awns such as ceMAc arneL APPROXIMATE INTERVAL
<br /> mpinrory ama4 or wnWcular BbdllAlvn without anowina do aaolosy. b0 NOT ABBREVIATE. EMar only one cause vn a line. Add addklonal Ilnee k mceseary. )
<br /> IMMEDIAT USE: onset to death
<br /> ..._ _..... ~ ~ ..... ............ ..._..v . i _ > f I` s
<br />IMMEDIATE CAUSE (Final ~
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<br />4
<br />disease or condition roaulting a) .,
<br /> In death)
<br /> DUE Tp, OR A CONSEOUENCE pF: onset to death
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<br />8equendrlly list condtdona, IT b) ~~ ~
<br />'" I ~~ /7b/i 7'4 S
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<br /> any, leading to the twat listed
<br />~ 1
<br /> on Ilna a. Due 70, OR A8 A ~ONSEpUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE al I
<br /> (disease or Injury ghat Initiated
<br />the events rosulling In death) DUE TO, OR AS A CONSEQUENCE OF: Dose! to death
<br />1
<br /> LAST I
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<br /> 18. PART 11. OTHER SIGNIFICANT CONDITIpNS-CtlndlUOni ContHb4fing to the death but not rosUlting In the underlying cause glVan In PART I. 1B. WAS MEDICA4 EXAMINER
<br /> OR CpRONER CO TACTED7
<br /> ^ YES Np
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<br />20. IF EMALE:
<br />21a. MANNER OF DEATH
<br />216. IF TRANSPORTATION INJURY
<br />21c. WAS AN AUTpP3Y PERFORMED?
<br />LL
<br />F
<br />~ot pregnant within pasty r
<br />~f6~ural ^ Hamlclda
<br />^ Drlver/Operator
<br />I;' YES
<br />W ^ Prognant at time oT death ^ Accident ^ Pending Invaangatlon ^ Passenger 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />U ^ Not pregnant, brit pngnent within 42 days of death ^ Sulclda ^ Could not be determined ^ Pedestrian CAU
<br />SE OF DEATH?
<br />TO COMPLETE
<br /> ^ Not prognant, but pregnant 41 days to 1 year before death ^ Other ISpeolryl ~
<br />~
<br />^ YES Lerno
<br />d []Unknown If pragnantwithin the peat year
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<br />22a. DATE pF INJURY (Mo., Day, Yc)
<br />226. TIME OF INJURY
<br />22c. PLACE OF INJURY-At home, fans, street, factory, office building, conatruc8on alts, rtc. (Specify)
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<br />22d. INJURY AT WORK?
<br />22e. DE8CRIBE HOW INJURY OCCURRED
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<br />^ YES ^ NO
<br /> 2.2f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br /> 2Sa. DATE OF DEATH (Mo., Day, Yr,) Z 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF bPATH
<br /> ~~ October 21 , 2008 ~i'NZ fn
<br /> W 21b. DATE SIGNED (Mo„ Dry, Yr.) 23c. TIME pF DEATH ~ 24c. PRpNOUNCED DEAD (Ma„ Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> ~~~ October 29,200$ 01 •02 A, m yi ~ m
<br /> g~c ,~ $
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<br /> 24e. On the basis of axamina8on endlor InveadgaUon, In my opinion death xcumd
<br />y y d. To s beat of owls e, death occurred at the dme, data and place ~ W
<br /> and ue to th ae(a feted. (Signature and Tltls) c P ~ at the time, data and place and due to the cause(s) stated. (Signature and Title)
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<br /> 25. DID TOBACCO US CON RIBUTE TO THE DEAT 28a. HAS ORGAN OR TISSUE DON BEEN CONSIOERED7 28b. WAS CONSENT GRANTED9
<br />'NO
<br />^
<br /> ^ YE$ ^ NO ROBABLY KNOWN ^ YES NO YES L~
<br />Not Applicable If 28a la NO
<br /> 27. NAME, TITLE AND AnDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Pdnt)
<br /> 'Ryan Crouch, D,O~, 800 Alpha St.•,.Cx'and Island, NE 6$801
<br /> 28a. REGISTRAR'8 SIGNATURE 2Bb. DATE FILED BY REGISTRAR (Mo., Dey, Vr.)
<br />8 2005
<br />~p ~ ' NOV
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