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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTid"AND HUMAN•SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKAr~pAk~MENT OF HEALTH AND
<br />HUMAN SERVICES, VI7"AL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOI~~VI~,v IL, J~~5' . ,
<br />DATE OF(ISSUANCE
<br />Q' S ZOOS S~ANL;EY ~aC~oP~ •~ ; ' ' '
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<br />` ~j ~i QY~PWr4TMENT OF IN,Eigf~~hl ,t}1y~
<br />LINCOLN, NEBRASKA HI~M,~ Sff1~IlICES , •~., ,•' c...'
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<br />CERTIFICATE OF I]EATH y~•~„ ~~~~~
<br /> 1. DECEDENT'S-NAME (First, Middle, Laet, Suffix)
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<br />i 2. SEX 3 bATE pF pEATF1 (Mo., Day, Yr.))~~
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<br /> atarme
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<br />Aiann Marie B File September 22, 2009
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<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AOE•Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Dey, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br /> Belgrade, Nebraska 67 November 4, 1941
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 505'-56-6566 HOSP1~4 : Q Inpatiem 9IHEB: ^ NursingFlome/LTC ^HvspicsFacility
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<br /> 86. FAGILITV•NAME (If n01 Institution, glue street and number)
<br />1~ ERlOutpetient ^ Decedent's Noma
<br />St. Francis Medical Center
<br />^ 004 D Olner(Speciry)
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<br />Bc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />8d. COUNTY OF DEATH
<br /> Gralnd Island 68803 Hall
<br /> 9a. RESIDENCE-STATE 96, COUNTY 9a. C17Y OR TOWN
<br /> Nebraska Hall Grand Island
<br /> 9d. STREET AND NUMBER ~ 9e. APT. NO 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />" ~ 1304 Mansfield Road 69803 f$ YES ^ ND
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<br />M 10a, MARITAL STATUS AT TIME OF DEATH ~ Ma«Ied ^ Never Married 106. NAME OF SPOUSE (Flrat, Middle, Lael, SutflX) II wife, give maltlen name.
<br />,z C7 Marrled, but separated ^ Widowed ^ Divorced Q Unknown Norman 8. ElatQrmeiear
<br /><" ~ 11. FATHER'S-NAME (First, Middle, Last, 5ulllx) 12. MOTHER'$•NAME (First, Middle, Maiden surname)
<br /> Henry R. Scheming Zolla Maria OstrandQr
<br /> 13. EVER IN U.S. ARMED FpRCE57 Glve dates of service If yes. 14a.INFORMANT•NAME 14n. RELATIONSHIP TO DECEDENT '
<br />~"'~. Norman B. Elstermeier Husband
<br />) NO
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<br />or unk
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<br />' 15. METHOD OF DISPOSITION . 18a. EM LMER•SIG T E 18b. LICENSE N0, t 6c. DATE (Mo., pay, Yr. )
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<br />~Burlal ^Donatian ~' 1 ~ ~ • September 25, 2009
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<br /> ^Gremation GEntombment 18d.CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />,, .' ~ O Removal ^ other (specdy) pyestlawn Memorial Park Cemetery, Grand Island, Nebraska
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<br /> 17a~FUNERAL HOME NAME AND MAILING ADDRESS (Street, Cily Or Town, State) 176. Zip Gvde
<br />', Kleine Funeral Home, 3213 W North Front 3'G., Grand Island, Nk: 68803
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<br /> 18. PART CEntar ih~ cpnillni ivents •disds~as, In)urles, or complli;atlons--that dfrectly`cause7th8"~eeth DO NO7 eriterleTm~nal events ouch (e cardiac~arrest, ~ APPROXIIgA7E INTERVAL
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<br /> respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add addlllonal Ilnes II necessary. l
<br /> IMMEDIATE CAUSE: I onset to death
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<br />IMMEpIATECAUSE(Flnal _ (a) (' cz...v d (a ~:, ~ -k'..
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<br />dlaeaaeorcondltlonreaulting DuETO,ORASACONSEQUENCEOF: I onset to death
<br /> In death) I
<br /> Sequentially Ilatconditions, If lb) I
<br /> any, leadingtothacauealiated DUE T0, OR AS A CON5EOUENCE OF: I onset to death
<br /> onllnea,
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<br />Enterthe UNDERLYING CAUSE
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<br />' (diaeasrarin)urythatlnltiated (c) l
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<br />iheaventareaultMgindeath) DUE 70, ORA3~~~_._.._. .. _
<br />ACONSEgUENCEOF: l onset to death
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<br /> 18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death put not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CON7ACTE07
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<br />, ^ YES ~ NO
<br />~ 20. IF FEMALE: ~ 21 a. MANNER OF DEATH 21 b. IFTRAN5PORTATIONINJURY 21c.wASANgU70PSYPERFORMED7
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<br />~ p Not pregnant wilnin past year ~ Natural LI Homicide ^ Driver/Operator
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<br />^ Pregnant at time of death ^ Accldent^ Pending Investigation ^Paesenger ~] YES ;~NO
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<br />r L:I Nat re Want, but re Want Within 42 da S of death
<br />p g P g y ^ Suicide ^ Could not be determined ^ Pedestrian
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE Tq
<br /> ^ Not pregnant, but pregnanl43 days to 1 year before death ~ Other (Specify) COMPLETE CAUSE OF pEATH7
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<br />a ~ ^ Unknown if pregnant within the past year ^ YES ^ NO
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<br />o a. DATE OF INJURY MO., Da Yr 22b. TIME OF
<br />) RY 22c. PLACE OF INJURY-At home, farm, street factory, office building, construction alts, etc. (Speclly)
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<br />22d.INJURYATWORK. 22e. DESCRIBE HOW INJURY OCCURRED
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<br />^ YES NO
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<br />22f. LOCATION OFINJURV-STREETS NUMBER, APT.NO. CITV/t'OWN STATE ZIP CODE
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<br />~~ 23a. DATE OF DEATH (Mv., Day, Yr.) = 2aa. DATE SIGNED (Mo., Day, Yr.) 246.TIME OF DEATH
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<br />TIMEOf]EgTy ~~~
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<br />CEpDEAp(Mo.,Day,Yr.) 24d.TIMEPRONOUNCEDDEAO
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<br />a 23d. To the best of my knowledge, death occurred et the time, date and place $ ¢ ~ 249.On the basis of examinaticn and/or investigation, in my opinion death occurred al
<br />o ~ and due to the cause(s) stated. (Signature and Title) ~ $ ~ $ the time, date and place and due to ih¢ cause(s) stated. (Signature end title) ~
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<br /> 25.DIDTOBACCOUSECONTRIBUTETO7HEDEATH? 28a.HASORGANORTISSUEDONATIONBEENCONSIDEREp7 28y.WASCONSENTGRANTED7
<br /> Q YES y~.+NO ^ PROBABLY ^ UNKNOWN ^ YE5 ~JO Not Applicable if 26e iS NO ^ YES ^ NO
<br />- 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN,GORONER'SPWYSICIANORCOUNTYA7TORNEY) (Type or Print)
<br /> Jennifer L. Brown, MD, 729 N star Ave., Grand Island NE 68803
<br />i ~ 28a, REGISTRAR'S SIGNATURE
<br />~ 28b, DATE FILED BY REGISTRAR (Mo., Day, Yr.)
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