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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ~~ukr~~( ERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASIf.A~ro~PAl~T~1~1,!17~~F HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIrALJ:~CORDS.' •~' ~ 1 d
<br />.~ f ~ ~ ~ 1 r
<br />DATE OF ISSUANCE ~~~~ ~ • ~,~'
<br />07/12/2010 2 010 0 5 $ 2 2 S~-A,~L~Y S. Co~~~ ~ ",
<br />ASSZSTANI~E~I~EISTRAR' '.,
<br />DEPAR~MEM F9~ L ~l ;4IND -
<br />LINCOLN, NEBRASKA HUMAM~~$ERVICES '
<br />STATE OF NEBRASKA - DEPARTMENT QF HEALTH AND HUMAN SERVICES ,~ ~' ,T. ~' vt:"•'~. r.'r ',
<br />(s, I a ::•,,-.' .:~~` w 10 01871
<br />CERTIFICATE OF DEATH ~ .. __
<br />., r.r
<br /> 1. DECEDENT'S•NAME (First, Mlddle, Last, Suffix) 2. SEX
<br />r . bATBQF DEAT.FriMo., Day, Yr.)
<br /> Gertrude Mae Clausen Female July 2,,2~i0
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Y~•) MOS. DAYS HOURS MINS.
<br /> Creston, Nebraska 83 Se tember 29, 1926
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 505-66-9935 H PIT ®Inpatlent JJTHER ^ Nurslnp HOma/LTC [] HosplCe Facility
<br /> 8b. FACILITY•NAME (K not Inatitutlon, glue street and number) ^ ER/Outpatient ^ Decadem's Home
<br />
<br />
<br />v Saint Fi"arte~"IV1~t~t,~T`Ceitit8w.. - ...~.. m , ~.~.. ~ ;~ . ,... ~ * ... [] ~- ... ... C7 canter1sa+car) .
<br />-
<br />~ 8c. CITY OR TOWN OF DEATH (Include Zip Gode) ed. COUNTY OF DEATH
<br />~ Grand Island 68803 Hall
<br />4 9a. RESIDENCESTATE 8b. COUNTY 9c. CITY OR TOWN
<br />w
<br />z Nebraska Hall Grand Island
<br />LL 8d. STREET AND NUMBER e. APT. NO. ef. ZIP CODE 9g. INSIDE CITY LIMITS
<br />,, 408 N. Kenned Drive 68803 ®YES ^ No
<br />~ 10a. MARITAL STATUS AT TIME OF DEATH ®Marrled ^ Never Marrlad 1Db. NAME OF SPOUSE (First, Mlddle, Last, Suffix) N wife, glue maiden name
<br />
<br />m ^ Marrlad, but separated ^ Widowed ^ Divorced ^ Unknown Willard M CIaUSSen
<br /> 11. FATHER'S•NAME (First, Mlddle, Last, Suffix) 12. MOTHER'S•NAME (First, Mlddia, Malden Surname)
<br /> August Wiemer Almuth Bruhn
<br />a
<br />E 13. EVER IN U.S. ARMED FORCES? Glve dates df service H Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ (res, No, or unk.) No Willard M Claussen Husband
<br /> 15. METHOD OF DISPOSITION 78a. EMBALMERSIGNATURE 164. LICENSE NO. 18c. DATE (Mo., Pay, Yr.)
<br />F ®8urlal ^ ponatlon
<br />Derek Apfel
<br />1240
<br />July 6, 2010
<br /> ^ Cremation 0 Entombmam
<br /> 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> ^ Removal ^ Other (Speclty)
<br /> Westlawn Memorial Park Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, State) 17b. Zlp Code
<br /> Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br /> AUSE F DEATH ee nstructlons an exam es
<br /> 19. PAitT I. Enter the chain of avanta--dlaaasas, InJurlea, or compllcatlOnadhat dlro0ty Cauasd the death. DO NOT aMar mrminal avaMa such as urdlac arrest, i APPROXIMATE INTERVAL
<br /> reapiratOry amat, or vanMcular ghdllatlOn without ahowing the etiology DO NOT A9l3REVIATE. Enter Only one cauw on a Ilne. Add addldpnal Ilnaa N necessary.
<br /> IMMEDIATE GAUSE: Onfiat to death
<br /> IMMEDIATE CAUSE JFInaI a)Aspiration Pneumonia ; 1 Day
<br />
<br />~.~.~...~-.,. _ .,,..xr .. ... ..
<br />disease or cOnditlOn resultlnq '
<br /> In d.^th) DUE TO, OR AS A GONSEQUENCE OF: J Onset t0 death
<br /> Sequentlalty Ilat condlllOna, If b) Alzheimers Disease 10 Years
<br /> any, leading to the nuae Ilatad
<br /> on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNUERLYINO CAUSE C)
<br /> (dlaaan or InJury that Inltlarod
<br /> the wants resultlnq In death) pUE TO, OR AS A CONSEQUENCE OF: i onset to death
<br /> LAST d)
<br /> 18, PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given in PART 1. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br />~ ^YES ®NO
<br />W
<br />LL 20. IF FEMALE: 27a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJUR 21 c. WAS AN AUTOPSY PERFORMED?
<br /> ^ No[ prognant within pawl year ®Natural ©Homlclde ^ DrWer/Operator
<br /> ^YES ® NO
<br />~ ^ Pregnant dt time Ot death ^ Accident ^ Pendlag InveetlpatlOn ^ Paaaenper
<br />T
<br />n ^ Not pregnant, but pregnant within sz days of death
<br />^ suicide ^ Could not bs determined ^ Pedeatdan 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />
<br />^ Nat prognant, but pregnant 43 days td 7 year belore death
<br />^ Other (Specly) TO COMPLETE CAUSE OF DEATH?
<br /> ©Unknown H prognant whnln the part year ^YES ^ NO
<br />~ 22a. DATE OF INJURY (Ma., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, rectory, omce building, construction site, etc. (SpaeHy)
<br />0
<br />~ 22d. INJURY AT WORK? 22a. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />~
<br />^YES ^ NO
<br /> 22f. LOCATION OF INJURY -STREET & NUMBER, APT.NO. CITYlTOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) _ . _ ,, ~,,,_ ~. _ _ 24a _gATE SIGNED {Mo., Dayr xr.) - 24b.-T1ML3 OF DEATW
<br />_ , ._ _
<br />
<br /> } 23b. PATE SIGNED (Mo Day, Yr) 23c. TIME OF DEATH ~
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> ~
<br />W ~ Jul 7, 2010 08:17 PM ~ ` Z~Z
<br />Z O
<br />~
<br /> ~ 7d. TO the Beal Of my knowledge, death occurred at the time, data and pWCe $$$
<br />P9e. On the basis Of examination and/or InwatlgatlOn, In my OplnlOn death oGCUrred at
<br />~
<br />~
<br /> and due to the wueela) stated. (Signature and Title)
<br />~
<br />the llny, date and place and due t0 the caueelel stated. (Signature and Title)
<br /> s William Landis, MD ~ a
<br /> 25. DID T08AGC0 USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br /> ^ YES ®NO ^ PROBABLY ^ UNKNOWN ^YES ®NO Not Applicable H 28a Is NO ^YES ©NO
<br /> I I ype or r n
<br /> William Landis, MD, 2444 W, Faidley Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED 8Y REGISTRAR (MO., Day, Yr.)
<br /> July 8, 2010
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