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STATE OF NEBRASKA
<br />WMEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WXTH THE NB'BRASKA DEP~RT'~MEIBIT QF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL"'R~CiRI~gS-. ~ '` `:
<br />DATE OF ISSUANCE 1 ~.,
<br />'~ ~ ~~~
<br />08/03/2010 2 0 1 0 0 5 9 9 6 ST,4"XILEY,S. C''OOPER "` "• '~ ,
<br />ASSISTANT S7'AfE F~'EGISTR,4R; , ,'
<br />DEPARTMEN~'b~l 1 ~ .AND
<br />LINCOLN, NEBRASKA HUINAJN SERV~C~3 l +~ _ -•a
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES; '. '~.~ QZ146
<br />CERTIFICATE OF DEATH ,
<br /> 1. DECEDENTS-NAME (First, Meddle, Last, SuTFlx) 2. SEX 3. DATE OF DEATH (MO., Day, Yr.)
<br /> Be Gretchen Petersen Female Jul 29, 2010
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last 8lrthday b. UNDER 1 YEAR Sc. UNDER 1 DAY e. DATE OF BIRTH (Mp., Day, Yr.)
<br /> IY-~d MOS. DAYS HOURS MINS.
<br /> Decatur, Nebraska 83 November 21, 1926
<br /> 7. SOCIAL SECURnY NUMBER 8a. PLACE OF DEATH
<br /> 551-34-7699 HOSPITAL ^ Inpatiem OTHER ®Nurslnq Home/LTC ^ Hospice Faculty
<br /> Bb. FACILITY-NAME (H rtot Institution, give street and number) ^ ER/Outpatiern ^ Dacadsm's Home
<br />
<br /> Wedgewood Care Center ^ DoA ^ othar(specHy)
<br />~ ea CITY OR TOWN pF DEATH (Include Zlp Code) Bd. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br /> 8a. RESIDENCE-STATE 9b. COUNTY 9c. GITY OR TOWN
<br />w
<br />x Nebraska Hall Grand Island
<br />~ 9d. STREET AND NUMBER 9e. APT. NO. 8!. ZIP CODE 9g. INSIDE CITY LIMITS
<br />;; 4235 S ur Lane 68803 ®YES ^ No
<br />~ 10a. MARRAL STATUS AT TIME OF DEATH ®Married ^ Never Mamlad 70b. NAME OF SPOUSE (First, Meddle, Last, SufflX) K w%e, plus maiden name
<br />!~ ^ Married, but separated ^ Widowed ^ Divorced ^ Unknown James Marten Petersen
<br /> 11. FATHER'S-NAME (Pint, Meddle, Last, Suffix) 12. MOTHER'S-NAME (First, Meddle, Malden Surname)
<br />d Lawrence Jensen Florence Thomas
<br />a
<br />E 13. EVER IN U.S. ARMED FORCES? Giva dates of service If Yas. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ (Yea, No, or unk.) No James Martin Petersen Husband
<br />a 15. METHOD OF DISPO5n-ION 16a. EMBALMER-SIGNATURE 186. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />~ ^ 8urlal ^ Dpnatlon
<br />Laurie D
<br />Sheffield
<br />1397
<br />Jul
<br />31
<br />2010
<br /> . y
<br />,
<br /> ®Cnmetion ^ Entombment
<br />
<br />^ Removal ^ Other (Specify) 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> Central Nebraska Cremation Services Gibbon Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, State) 77b. Zip Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> AU E F DEATH See instructions and exam les
<br /> ia, PART I. Enter the yhpln ofevents-.diseases, Injuries, or complicadons•that directly caused ttw death. DO NOT enter mrminal evsms such as cardiac arrost, ;APPROXIMATE INTERVAL
<br /> roapirotary arroat, or venMcular ahdllation wknout showing the etlolopy. DO NOT ABBREVIATE. Einar onty one cauw on a Ilne. Atld addklonal lines I} necsuary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (ilnH a) Progressive Dementia ;Years
<br /> dlaeasa ar condition resulting
<br /> In death) DUE TO, OR AS A CONSEQUENCE OF: I Onset t0 death
<br /> Saqusntlalty uat Condltlona, If t1)
<br /> any, leading to the wuee listed
<br /> on Ilne a. DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br /> Enter the UNDERLYING CAUSE C)
<br /> (diseaea or injury that Innlatea
<br /> ens events reauninp In deatnJ DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br /> LAST dl
<br /> 18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contrl6uting to the death but not resulting In the undarlying cause given In PART I. 19, WAS MEDICAL EXAMINER
<br /> Seizure Disorder,hypgthymidism, Histpry Of Pulmonary Embolism OR CORONER CONTACTED?
<br /> ^ YE$ ®NO
<br />~,
<br />W 29. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br /> ^ Not prognant wkhln pea! ysar ®Naturol ^ HomlCida ©DriverlOparetor ^ YE$ ® NO
<br />~ ^ Pregnant at time of death ~ Accident ~ Pandlnp Invesnpation ^ Paseender
<br />
<br />~+ ^ Not prognant, but prognant within 42 days of death
<br />^ Sulclde ^ Could not be detarmlrwd ~ Pedastrlan 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />
<br />9
<br />^ Not pregna~d, but pregnant u days to 1 ysar baton death
<br />^ Other (Specify) TO COMPLETE CAUSE OF DEATHS
<br />+~
<br />d ^ Unknown If prognant wllhln the pact year ^YES ^ NO
<br />a
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, offlca building, construction site, etc. (Specify)
<br />S
<br />S~ 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />~"
<br />^YES ©NO
<br /> 22f. LOCATION OF INJURY -STREET 8, NUMBER, APT.NO. CnY/TOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) ~ 24a. DATE SIGNED (Mp., Day, Yr.) 246.71ME Cu= DEATH
<br /> ~ W Jury a9~ 2010 ~' ~ W
<br /> ~'
<br />236. DATE 81GNED (Mo., Day, Yr.) 23c. TIME OF DEATH ~ ~ 24c. PRONOUNCED DEAD (Mo., bay, Yc) 24d. TIME PRONOUNCED DEAD
<br /> ~
<br />~ z Jul 30, 2010 07:55 AM ~
<br />e a ~
<br /> O 3d. To the 4eat of my knowledge, death occurred at the time, date and place
<br />i
<br />~ $ ;5 ~ ~
<br />~ 4 Y49. On the bases of sxaminatlon andlor Inwadgallon, In my aplnlan death accumd a[
<br /> and due to the cause(s) stated. ISipnature and Tk
<br />a) o the elms, data and Placs and due to the caussls) stated. (8lpnature and Tkiel
<br /> ~ Jane A, McDonald, MD ~ ~ 5
<br /> 25, DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TI83UE DONATION BEEN CONSIDERED? 28b. WA$ CONSENT GRANTED?
<br /> ^ YES ®NO ^ PR08A8LY ^ UNKNOWN ^YES ®ND NOt Applicable K 28a 18 NO ^YES ^ NO
<br /> 2 A E ypa or rent
<br /> Jane A, McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> August 2, 2010
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