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<br />STATE OF NE6RASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND F1UN1Ald'SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORb pN FILE WITH THE NEBRASKA (7,~11~ML~l4tT ~OF~F'J~ALTM AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAI. k~CQ1~b~s ' ~ r
<br />DATE OF ISSUANCE .,, '
<br />STAI~t;_~~' S...G~lG1l7~ r r
<br />MAR o b zoo 2 010 0 2 3 x 4 ASzSI3'~~IIVt~3~,471~F./t~G7S„~RAR , ,',/
<br />DEPAI~',TMENT OF,/-1EACThi ANDS. , • ''
<br />LINCOLN, NEBRASKA HUINAN' $ER~/~CES. .~ • t'~ ''
<br />STATE OFNEBRASKA- DEPARTMENT OF HEALTH ANp HUMAN SERVICES FINANOE AND SUYPOR'ICf ~~' ''ti
<br />CERTIFICATE OF DEATH ~ ~ ".. . ' ~.Q
<br /> _ 1. DECEDENT'S-NAME First, Middle, Last, 5ulfix 2. SEX 3. DATE OF DEATH Mc., Da , Yr.
<br /> Karam Dianne Kleine Female February 24, 2010
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<br /> 4, CITY ANp STATE OR TERRITORY, OR FOREIGN COUNTRY OF 9IRTH 5a. AOE-Last Birthday 5b. UNbER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTW (Mo.,
<br />Dey, Yr.)
<br /> (Yrs.) MOS. DAV$ HOURS MIN5.
<br /> Beatrice, Nebraska 65 Marsh 9, 1944
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<br />7. SOGIAL SECURITY NUM
<br />8ER 89. PLACE OF DEATH
<br /> ~.. 3$ HOSPITAL:. Q~Inpatie_nt .. ,.L2T.'lEB: QNursingHome/LTG. G]Hosplc6Faculty
<br /> rib. FACILITY-NAME (If not institution, glue street end number)
<br />^ ERlOutpatlent ^ Decedent's Home
<br /> St. Francis Mediae]. Center ^ m,, ^other(specify)
<br /> - Bc. CITY OR TOWN OF DEATH -(Include Zlp Code) ~ T. ed. COUNTY OF DEATH
<br /> Grand Island 68803 Hall
<br /> - ga.RESIDENCE•5TATE 9b.000NTY Bc.CITY0R70wN
<br /> Nebraska Hall fdrand Island
<br /> 9d. S7REETANDNUMBER 8e. APT. ND 9f. ZIP CODE 9g. IN51bE CITY LIMITS
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<br />- 2414 Vatsdergrift Ave. 68803
<br />,_.._...,-T 4a vl=s ^ No
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<br />' i0a. MARITAL STATUS AT TIME OF DEATH ~ Mewled ^ Never Married 106. NAME OF SPOUSE (FiraL Mlddle, Lest, Suffix) If wife, give maiden name.
<br /> ^ Married, but separated ^ Widowed ^ Olvarced ^ Unknown
<br />- - ._ _._ Larry G. Kleine
<br /> it. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S•NAME (First, Mlddle, Malden Surname)
<br /> Ira Lloyd Metcalf Eloise Mary Fame Stephenson
<br /> 13. EVER IN V.S. ARMED FORCES? Glve dales of service If yes. 14a. INFORMANT•NAME t4b. RELATIONSHIP TO DECEDENT
<br /> - (vas, no, or unk.) No harry (3. Kleine Husband
<br /> -- 15. METH00 DF pISPO51TI0N 16a. EMB MER-SI TUR 18b. LICENSE N0. i 6c. PATE (MO., Day, Yr. )
<br /> I'~Burial ^banation ~ March 1, 2010
<br /> ^Cremation ^Entombmenl _
<br />16d.CEMETERY, CREMATORY OR OTHERLOCATION ~ CITY/TOWN STATE
<br />a ~ ^Removal UOther(Spacify)
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<br />.. Grand Island City Cemetery, Grand Island, Nebraska
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<br />NAME AND MAILING ADDRESS (Street, Clty orTown, State) 17b. Zip Code
<br />17aFUNERALHOME
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<br />~~ K1aaLna Funeral Home, 3213 ~P North Froxxt St. , Grand Island, NE 68803
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<br />18. PART I Enter the gp~p,pjgyyp~q--diseases, In)urlea, or compllcallane••that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br /> reaplratory arrest, a ventricular librilladpn withcut showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Ilnea II necessary. I
<br />-' .~~; IMMEDIATE CAUSE: i onset to death
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<br />IMMBDIATBCAUSB(Flnal lfl) Re..s P ~ r ~~_ __~___ ,_~ W'CaL.
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<br /> ~• " dlaeaceoroondldonreeuking DUE T0, OR AS A CONSEQUENCE OF:
<br />I onset to death
<br />_ In death) I
<br />`~ ,,_; Sequentlallylletcondltlone,if (b)~ ~~r~~.~ ~ ~ ~, U 1 '•q I ~ ~] ~t...4+ „,J
<br />' i<'L.. any, leading to the dau9@Ileted ........_-......._....-..~_.
<br />DUETO,ORASACONSEQUENCEOF: I anaettodeath
<br /> ~^ on line a. I
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<br />1 Enkrttw UNDERLYIND CAl15E
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<br />~~: (dleeaeedrlnJurythatlnltlated (c) I
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<br /> '~r~ ffiaewnfa resulting In death)
<br />DUE T0, OR AS A CONSEQUENCE OF: I onset to death
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<br />~?~ LAST
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<br /> - 18. PART IL OTHER SIGNIFICANT CONDITIONS•Condglona cantrlbuting to the death bur not resulting In the underlying cause given In PAg7 I. 19. wA$ MEDICAL EXAMINER
<br /> OR CORONER CON7AC7Ep?
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<br /> 20. IF FEMALE: 21a.MANNEROFOEATH 21 b.IFTRANSPORTATIONINJURV 21c.wASANAUTOP$YPERFORMEp7
<br /> 6~Notpregnentwlihlnpastyear ~Neturel ^Homlclde ^Driver/Operetor
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<br />^ P ^ YES O
<br /> ^ Pregnant at time of death ^ Accldent^ Pending Investlgatlan assenger
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<br />~'• ^ Not pregnant, but pregnant within 42 days of death
<br />^ Suicide Q GOUId not be determined ^ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
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<br />^ Notpregnant.butpregnant43daystolyearbeforedeeth ^ Other ($pCClfy)
<br />COMPLETE CAUSE OF DEATH?
<br /> ^ Unknownit pregnant within the past year ^VES ^ NO
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<br />'rPr 22a. DATE OF INJURY (Mn., Dey, Yr.) 226. TIME OF INJURY
<br />m 22c. PLACE OF INJURY•At hams, farm, street, factory, ofllce building, construction alts, etc. (Specify)
<br /> 22d.INJURYATWORK? 22e.DEBCRIBEHOWINJURYOCCURREb
<br /> p YES [,~ NO
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<br />22f. LOCATION OF INJURY • STREET 8 NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br /> a 23a. bATE OF DEATH (Md., Day, Yr.) x ~ 24x. DATE SIGNED (Mo., Day,,Yr.) 2ab.TIME OF pEATH
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<br />7IME PRONOUNCED DEAD
<br />TIME OF DEATH ~
<br />23b
<br />DATE SIGNED (Mo
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<br />24c
<br />PRONOUNCEp DEAD (Mo
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<br /> v 24e. On the basis tlf examination endlor Investlgatlon, In my opinion death occurred at
<br />23d. To the best of my knowledge, death occurred fll the time, data end place
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<br />and due to the cause s) stated. (Signature and Title) ~
<br />p p the time, data and place and due to the cause(s) state
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<br /> ' 25. DID TOBACCO USE CONTRIBUTE TOTHE DEATH? 28e. HAS ORGAN OR TISSUE pONATION BEEN CONSIDERED? 26b. WAS CONSENT QRANTEb?
<br /> '~,. ^VES ~NO ^ PROBABLY ^ UNKNOWN CI VES ~NO Nat Applicable if 26a is NO ^ YES ^ NO
<br /> 27. NAME, TITLE ANDApDRES50FCERTIFIER (PHYSICIAN,CORONER'$PHV3ICIANOR COUNTY ATTORNEY) (TypaorPrlnt)
<br /> Jennifer Ir. Brown, MD, 729 N Custer Ave., Grand Island NE 68803
<br /> 2Ba. REGISTRAR'S $IONATURE 28b. DATE FILED ~ ~GBSISTRAF~My~ f~;yy~'r.)
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