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STATE OF NEBRASKA
<br />WHEN TMIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTl~,74~C'DrMU~A~I"~~RVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA~CA`{lAi~tML~11(T O~HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR,11P'~~tL ~~ti its: • •;'' ~: , "
<br />"~ k G"
<br />DATE OF ISSUANCE ~~~d~ , .,.~Y"
<br />06/22/2009 ,~ ~ 10 0 ~ ~ 9 5 Ana~Y S toaPER 1' r;
<br />iA'ra`S~~"AN~"$1'iA~Ei ~r~~,r~~Q~ ~ .'
<br />D~P1~~27MENT OF HEALTI?f"~1WD~; ~"'
<br />LINCOLN, NEBRASKA HLJM.~A! SE~i JIICES ~ ,i„ ,-' ,,'' ,';'
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND WUMAN SERVI'C~S;~^„ "~•~,~-' I i.,1 t`.'.`.,~ ` `,~ti~ ~~ 09 01304
<br />CERTIFICATE OF DEATH ` ' ''~" ,•,~,;','; :~;'~``~~'` ~.
<br /> 1. DEGEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX "„ 91 7TH ATE QF .DEATH (Mo., Day, Yr.)
<br /> Lar Edward Ro le Male 1un~' 14, 2009
<br /> 4. CITY AND STATE OR TERRITORY, pR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 7 YEAR 5c. UNDER 7 DAY e, PATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yr:•I MOS. DAYS HOURS MINE,
<br /> Sherman County, Nebraska 70 March 20, 1939
<br /> 7. SOCIAL SECURITY NUMBER Ba. PLAGE OF pEATH
<br /> 506-4$-1579 HOSPITAL ®Inpatlent THER ^ Nursing Homa/LTC ^ Hospice Facility
<br /> 8b. FACILITY•NAME (IT not Institution, give str9et and number) ^ ER/Outpatlent ^ Decedent's Home
<br />a
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<br />~
<br />5aint Francis Medical Center
<br />^ DoA ^ other(spetllty)
<br />.
<br />~ 8c. CITY ORTOWN OF DEATH (Include Zip Coiie) 8d. GOUNTY OF pEATH
<br />o Grand Island 68803 Hall
<br />J 9a. RESIDENCESTATE 8b. COUNTY 9c. CITY OR TOWN
<br /> Nebraska Hall Grand Island
<br />~ 9d. STREET AND NUMBER 99. APT. NO. 8f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />~, 112 W. Charles St. 68801 ®YES ^ No
<br /> 10a. MARITAL STATUS AT TIME OF DEATH ®Manled ^ Never Manled tOb. NAME OF SPOUSE (First, Middle, Last, Suffix) tF wtfe, plve maiden name
<br />:`
<br />a ^ Married, put separated ^ Wldowad ^ Divorced ^ unknown GeCllla Bridget Hruby
<br /> 11. FATHER'S-NAME (First, Middle, Laat, SufFlx) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br /> Bernard Boyle Marie Hansen
<br />a
<br />E 13. EVER IN U.S. ARMED FORGES? Give dates Of 89rvIC9 If VBS. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yes, No, or Unk.) NO Cecilia Bridget Ro le Wife
<br />~' 15. METHOD OF DISPOSITION 15a. EMBALMERSIGNATURE 78b, LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F ®Burlal ^ Donation Daniel D Naranjo 1071 June 18, 2009
<br /> ^ Cremation ^ Entombment
<br />
<br />^ Removal ^ Other (Specify) 18d. CEMETERY, CREMATpRY pR pTHER LOCATION CITY /TOWN STATE
<br /> Pleasant Valley Cemetery Sherman County Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code
<br /> All Faiths Funeral Home, 2929 5. Locust Street, Grand Island, Nebraska 68801
<br /> F DEATH See instructions an exam es
<br /> 18. PART I. Enter the chain or events-.diseatas, Injuries, or complicatlona-that directly caused the death. DO NOT enter terminal evens ouch ae cardiac arrest, ) APPROXIMATE INTERVAL
<br /> respiratory arrest, pr ventricular flbrillatlon wltnout antlwlnp the etiology. DO NOT ABBREVIATE. Enter only One Ceuta on a Ilea. Adtl atltlnlonal Iinee IT necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAU8E (Final a) Sepsis ;Days
<br /> dltsdse or contlnion recalling
<br /> In duth) DUE Tp, pR A$ A GONSEQUENCE OF: onset to death
<br /> $squentlally Ilat cpndalona, If b) Pneumonia ;One Week
<br /> any, hadlnq Tp the cause Ilatad
<br /> on Ilne a.
<br />DUE Tp, OR AS A GONSEQUENGt: OF: :Onset tD death
<br /> EntartheUNDERLYINGCAU$E c)Metastatict.ungCancer
<br /> (dlaaase or Injury that Initiated
<br /> ms awMa resunlnq In death) pUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br /> LASr d)
<br /> 18. PART II, OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resuking In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTAGTED7
<br />y ®YES ^ NO
<br />W
<br />w 20. IF FEMALE: 21a. MANNER OF DEATH 27b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />~ ^ Nat pregnant wlthln peal year ®Natural ©HomiCltle ^ Drlvar/OparotOr
<br />
<br />U
<br />^ Pregnant at tines oT death
<br />^ Accident ^ Pandlnp Invsrdl9atlpn
<br />^ Passenger ©~.E$ ® NO
<br />
<br />~' ^ Not pregnant, but pregnant wlthln A2 days of death
<br />^ Sulfide ©Could npt ba determined ^ Pedeatdan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />
<br />^ Not pregnant, bu! pregnant 4S days to 1 year befpn death
<br />^ Other (Speclyl TO COMPLETE CAUSE OF DEATH?
<br /> ^ Unknown IT pregnant wnhln the past year © YES ^ NO
<br />~- 22a. DATE OF INJURY (MO., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, str9et, factory, office building, construction alto, etc. (Specify)
<br />c4
<br /> 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />Q
<br />~
<br />^YES ^ NO
<br /> 22f. LOCATION OF INJURY -STREET 8 NUMBER, APT.NO. CITY/1"OWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) ~ 24a. DATE SIGNEb (Mo., Day, Yr.) 24b. TIME pF pEATH
<br /> ~ ~ June 14, 2009 ~' ~ ~
<br /> rn } 2sb. DATE SIGNED (MO., Day, Yr.) 23c. TIME OF DEATH ~ ~ ~ 24c. PRDNOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> ~ o June 16, 2009 09:21 AM E d a ~
<br /> 3d. To the bast of my knowledge, death occurred a[ lha time, date antl piece
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<br />and due to the causa(a) stated. (Slgnaturo and Title) $ ~ ~ O
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<br />24e. On the baala of axaminatipn andlor Invaatlgatien, In my Opinion death pccurred at
<br />the time
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<br />~ Travis 5. Hageman, Mp p
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<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE PEATH7 28a. HAS ORGAN OR TISSUE DONATION BE@N CONSIDERED? 28b. WAS CONSENT GRANTED?
<br /> ® YES ^ NO ^ PROBABLY ^ UNKNOWN ^YES ®NO Not Applicable If 28a Is NO ^YES ^ NO
<br /> DAD 11 ( 1 ype or r n
<br /> Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED 8Y REGISTRAR (Mo., Day, Yr.)
<br /> June 17, 2009
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