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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF H~AL1'H.,~h11B 1'lt1MANwSrGRVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE~RA.SJtA ~ERARTMENT"QF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE WHICH IS THE LEGAL DEPOSITORY FOR-1!IT/It~ RECORDS,
<br />DATE OF ISSUANCE a[J
<br />~r ,
<br />,JUN 3 o zoo ~~~ ,cQo~R , „ .• ,
<br />2 010 0 5 4 0 3 ~,s~,aT~v~~crst~RAra '
<br />L~EPI4RTM T°U~1iEA~T'tl A?VC~
<br />LINCOLN, NEBRASKA HUh~`AI~V. SE~tVICES _ =
<br />STATE OFNEBRASKA -dEPARTttENT CF H=ALTH A1Jd HUMAN SERVICES FINANCE ANE~,$Uf~ -~ ~ y- • f _
<br />L ~~. •.
<br />- CERTIFICATE OF DEATM ~1 '
<br />I. DECEDENT'S•NAME (Fllat, Mlddlr, LiU- SutNa) t. SEX 3:tlATFOFpEATH(M8'I;pay,Yr.)
<br />Paul Robert Lee 5ensenbach Male ~ 3epteriTbe~2~ 2007
<br />1. CITY AND STATE OR TERRITORY. pR FOREIGN COUNTRY DF BIRTH :a F_E•Lati: E~rmday 5b, UNDER r YEAR 5C. UNDER I DAY 8. DATE OF BIRTH IMd.. Day. YLI
<br />;Y Y) M05. DAYS HOURS M1NS.
<br />Newark. Ngw,Jersey $7 Jul 16, 1926
<br />7. SOCIAL SECUpITY NUMBER ' Ea A'.A,9E OF DEATH
<br />142-16-4908 ^e~ P!TAL- J Inpatient 41NER ^ anrsingHnmerLTC ^HgspicrFadllry
<br />Sb. FACILITY•N AME pl not Indrluli on. giVp street and number]
<br />W .] ERroutpabenl b Decedents Ngmr
<br />u
<br />cL ec. Ctrl OR TOWN OF pEATH (Incluge LP Codal Bd. COUNTY DF pEATH
<br />¢ Grand Island 68801
<br />W Hall
<br />x Ea. RESIDENCE~STATE Pb.000NTY SC.GITYDAT04YN
<br />~• Nebraska Hall Grand Island
<br />v 9d.5TREETANDNUMBEA
<br />c ge.APT.NO 91. ZIP CODE gq.IN510ECITYLUIIT3
<br />3103 West 15th 68801 ~ YES ^ Np
<br />a IGa. MARITAL S IA(US wf i rME OF DEATH .xi Marrlyd ~ NrVer Maui..tl I'C. !:.".!:.E :F een~,G C_ ~Fl„r, M,ddle, Lasf, AugiR) 11 wllo, giyy maidxn namr.
<br />.y .. •
<br />a ^!Aarned.bulseparalyd ^Widpw4d ^puwced ^Unknown '
<br />_ Kalh_prine Parlier
<br />~m 11. FATHER'5•NAME (Flrsl, Mlddlr, Laat. 5ulhal ~ 1:. MOTHER'S•NAML (First, Middle, Ma,d:n Surname)
<br />r= Eu ene Gu Sensenbach Ethel Mae Fairchild
<br />I~. EYEA IN U.S. ARMED FDRGES7 GIv4 dales pl eervlcr it yrs. 14a.INFORMANT•NAh1E 116. RELATIONSHIP TO DECEDENT
<br />Ir. a,nd.grunk.) No Katherine SensenbaGh yy;te
<br />15. METHOD DF p15POSITION 1fi MgALMER-SIGNATURE re~~ 166. uCENSE N0, 18c. BATE (Ma„ Day, Yr.) -
<br />018unal ^ pgnaDgn eLac oa~~[,~ / 7 ~F,3 October 3, 2007
<br />^Cremaudn ^Enlpmbment 160.GEMETEAY,CAEMAi0RY0ROTHERLOCATION GITYrTDWN STATE ,
<br />CI Remduel ©Other I5peaty)
<br />Wesllawn Memorial Park Grand Island Nebraska
<br />17a. FUNERAL HOME NAME ANp MAIUING ADDRESS Istrrrt, City drTgwn, Slate) 17b. Zlp Coda
<br />LivingsWn-SOndermann Funeral Name, 6D1 N, Webb Road, Grand Island, Nebraska 68803
<br />CAUSE OF DEATH (sea instructions an examples
<br />1E. PARTr.Enlerhechaing,~events••ciseases.InlUdee,dreompllatfons••lnalAlreceycausedlhedeals.DONOTenlrrterminalevenlysuchaeCerglaearrest I APPROxIMATEINTERVAL
<br />respiratory arrest-orvemrlcularlipfilauan without showing ln6 etiglagy. Dp NDT A55AEYlATE. Fnleranly qna cause Dn4line.Add addlpdnat Ynes it necessary I
<br />IMMEDIATE CAUSE: I dneeltgdreth
<br />IMMENIYEC~.USE(Fhal ~_ RespiraCQry Arrest I
<br />dl:4.u,a :u id,,:;rrtwady DUE TO,OR ASACUraEDUkrvGE (iF: + Vn-ri to ur:.ri.
<br />h deelM
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<br />9equenwly ustcondNone, n ~ CDPD (
<br />erty,leadulglgpleeeusekated pUETO,ORASACDNBEpUENCEOF: I
<br />qn ene e. 1 onset l0 deals
<br />Enter htUNDERLYtNOCAUSE r
<br />(dleeeer W lalury that Inl{lahq ICI I
<br />th~r wenrcnmelnq In eeagl) pUE iD.OR ASACON5E0UENCE OFD ( onset lgdeeth
<br />I
<br />Idl 1
<br />1 PAATILOTHERSIGNIFICANTCpNpITIpNS•Cgndili0necontdbutingl0thedealnbulnOlresullinqintneunderrymqceuaeqrvenmPAATI• tgriVASMEDICALEXAMINER
<br />0R CORONER CONTACTEq'r
<br />YES ^ NO
<br />~ 20 fFFEMALE: 21a,MA ER OF pEATH ylp,rFTRANSPORTATIONINJURY ~:WASANAUTOP5YPERFORatEp?
<br />~ ~
<br />~,r ^ NgtPregnanlwlihinpaslyrar Natural QFigmlade I~OdverrOpaatnr
<br />V ^ Pregnanlal ume ql Oealh ^ Accident!] Pendnq hvestlgau0d ^ Pucenger ^ YES Np
<br />^ Notpre~nant,pulpregnanlwiWnl2daysot0eah ~ ^PedestAan 7~WEREAUTOPSYPoNDRJGSAVAILAI)LETO
<br />^ 5uode ^ GoWd ndtbe delertnined /`~ ~~
<br />'d ^ Nvlpregnanl,butpregriarae3daysldtyearpalpredeah ^Ofher(Speary) COMPLETEGAUSEOFDEATH?
<br />3
<br />~ ^Unknownitpregnantwidlinthepaslyear _.__•,•_-._••_ ^ rF3 ^Nrr
<br />I ° ~a. DATE OF INJURY (Mp,. Day, Vr.) rZ2b, TIME OF INJURY P~CPLA~.E OF INJURY-Alndme, IamL etreal, factory. ghee pulldrnq, cgnslructldl6tie. elc.(Specity) W-
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<br />yT,]~;r:JI~HYATV:,,iiK'! ~Itf,.DtSCRItlEHU.MNr,IURY000URAED ~~-•~~
<br />[] YES ^ ND ~"
<br />~I. LOCATION OF INJURY • STREET 8 NUMBER, APT. N0. CIT1•,TWVM STATE ZIP CODE
<br />~~ 7~a.DATEgFDEATH(Md.,DaY.Yr.) ~r 24a,pATE51GNEDtMv.,Day.Yr.) 2aD.TIMEOFpEATH
<br />~ ~' i3 ¢ m
<br />~~y '.22b. DATE SIGNED (Md.. Day, Yr.)~,tfrTIA1E OF pEATH ~_~ f ~a p,pppNgUNCED DEAD (Mb., Dey, Yr.) 21q.TIME PRgNIX1MCEDDFAD
<br />~ azo 1Y'~~ m n¢~i!f m
<br />i ~ ~ ~ a sl pr my Nngwiedge, tleatn dccutra l the bma, dale ind place z ~ 2ee. On he payf pl examnaenn endrgnmeaugaAdn. m my dpnrondealh 4ceuned al
<br />t~~~~• tl rl Ih/caui Nilale0. t and Tlp! •
<br />F ~ ~ 1 ~ f~ a ~ ~ Iha ume, garr an0 place anddur m mr eada4(s) staled. {Signalurr and Tnlq) •
<br />D flAGCOUSECONTRI6UTET0THEDEATH7 ~~.HASOR6AHORTISSUEfpjppATIONBEENCONSIDERED~ '{rbWASCONSENiGRANTE00
<br />)'ES.~Q HO ^ PRDBABLY Q UNKNOWN ^ YES L] NQ Nql Appllcaulr It Y8a if Np ^ YES ^ NO
<br />AM DDRESSOFCERTIpIER(PHY CORONERSPHVSIGIANORCOUNTYAT70RNEY)lTypeerPnnn
<br />William d LawCon, M.D., 2444 W F~(idle Ave Grand Island KE 688D3
<br />• ~ YBa.RE¢ISTRAR'SSIGNATURE 28b.DATEFILEDFIYREGISTRAR(MO..Day.Vr.)
<br />~ ,~'~~, ~. ~~• . v DCT i 7 2007
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