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<br /> STATE OF NEBRASKA
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br /> SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br /> THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br /> DATE OF ISSUANCE
<br /> 9~ ` r
<br /> .lug o s 2007 201006 27 2 t
<br /> ASSIST ' $T47E 14ErW19~R F~' ,
<br /> LINCOLN, NEBRASKA HE;~ *1 AND HUMAN S fiFJ4 yS
<br /> STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES FINq E. N
<br /> CERTIFICATE OF DEATH y - . 4'.'. ' ,
<br /> L DECEDENT'S-NAME (First, Middle, Last, Sulflx) 3. DATE OFDEhtH (Mo, ~Day,Yr.)
<br /> Michael James. Seim 6e
<br /> ' Jun~ll q 2QQ
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 6a. AGE-Last Birthday 5b. UNDER 1 YEAR 6c: UNbEM VilIAi' W
<br /> --WE oFa;IgTH° (Mo„ Day. Yr.)
<br /> (Yrs.) F MOS, DAYS HOURS
<br /> Grand Island, Nebraska 62
<br /> June 3,194&
<br /> 7. SOCIAL SECURITY NUMBER Be. PLACE OF DEATH
<br /> 508-54-4158 QSPITAL: ®Inpatient 91M ❑NursingHome= 0 Hospice Facility
<br /> Ob. FACILITY-NAME cif not Institution, give street and number)
<br /> ❑ ERlOUlpallanl ❑ DeCedenre Herne
<br /> Saint Francis Medical Center ❑ DDn ❑ Osier(spedfy)
<br /> 8c. CITY OR TOWN OF DEATH (Include Zip Code) ed. COUNTY OF DEATH
<br /> Grand Island 68803 Hall
<br /> ga. RESIDENCESTATE IA. COUNTY ga. CITY OR TOWN
<br /> Nebraska Hall Grand Island
<br /> 9d. STREET AND NUMBER go. APT, No 01. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 1804 Idlewood Lane 88803 tea YES ❑ NO
<br /> 10a. MARITAL STATUS AT TIME OF DEATH W Married Ol Never Married 10b. NAME OF SPOUSE (First. Middle, Last, Suffix) II Wile, give Malden name,
<br /> I O Married, but separated ❑ Widowed O Divorced ❑ Unknown
<br /> Jane East
<br /> e
<br /> 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12, MOTHER'S-NAME (First, Middle, Malden surname)
<br /> i2 Harold George Seim "Loraine- Helen Renken
<br /> 13. EVER IN U.S. ARMED FORCES? Give dates of service It yes. 14a.INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yes,no,orunk,) Yes 09/23/196409/22/1970 Jane Seim Wife
<br /> 16, METHOD OF DISPOSITION 168LMER-SIGNATU 16b. LICENSE No. 16c. DATE (Mo., Day, Yr. )
<br /> ® Burial ❑ Donation 1071 June 23, 2007
<br /> ❑Cramatlon ❑kritorbment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br /> ❑Removal ❑Omer(specify)
<br /> Grand Island City Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street. City orTown, Slate) 17b. Zip Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 66601
<br /> CAUSE OF DEATH- (lee instructions. an examples)
<br /> 1S, PART I. Enter the rh6lsol evente--diseases, Injuries, or compllations--that directly caused the death, DO NOT enter terminal events such as cardiac anent, I APPROXIMATE INTERVAL
<br /> respiratory arrest, or ventricular tlbdllstion without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. I
<br /> IMMEDIATECAUSE: I onsellodseth
<br /> I
<br /> IMMEONTFCAU$9(Fklel (a) I p+
<br /> disomorcamdltlenresutiing DUE TO, OR AS A CONSEQUE E OF,
<br /> In dnSq I onset to deem
<br /> 1
<br /> Sequenlially list conditions, it (b) I
<br /> rsM, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: I
<br /> an line a. I onset to death
<br /> EnW#W UNDERLYINQCAUSE I
<br /> (dHeea or lni ry that initiated (c) I
<br /> pleWentermillinghdrsF) DUE TO, OR ASA CONSEQUENCE OF:
<br /> LAST I onset to death
<br /> (d) I
<br /> is. PART 11. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in PART 1, 1B. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED-)
<br /> ❑ YES ❑ NO
<br /> 20. IF FEMALE: 216. MANNER OF DEATH 21b, IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED7
<br /> © Not pregnant within past year "mural QHomicide 11 Ddve0operalor
<br /> 13 Pregnant at time of deem ❑ AccldaniO Pendng Investigation ❑ Passenger 13 YES Q46
<br /> Q Not pregnant, but pregnant within 42 days of death ❑saclde L7 could not be determined L3 Pedestrian 21d. WEREAUTOPSY FINDINGS AVAILABLE TO
<br /> ❑ Not pregnant, but pregnant 43 days to 1year before death ❑Other(Specify) COMPLETE CAUSE OF DEATH?
<br /> ❑ Unknown 11 pregnant within the past year Q YES W-blia'
<br /> 22a. DATE OF INJURY (Mo., Day, Yr.) 22b, TIME OF INJURY 22c, PLACE OF INJURY-At home, farm, street, factory, office building, constnlction site, etc, (Specify)
<br /> M
<br /> 22d, INJURY AT WORK? 22s. DESCRIBE HOW INJURY OCCURRED
<br /> ❑ YES 114410
<br /> 221. LOCATION OF INJURY-STREET d, NUMBER, All NO. CITYITOWN STATE 71PCDOE
<br /> 238. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day,Yr.) 241). TIME OF DEATH
<br /> June 19, 2007 sr)z m
<br /> 23b. DATE SIGNE (Mo.,~ y Yc.~ 23c. TIME OF DEATH 319 24o. PRONOUNCED DEAD Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> Igo June 2 , Q 3:15 P.m 311 l
<br /> m
<br /> 13 ° O d. To th6 6 kno deem urred al ma time, dale and place is
<br /> ~ 9 246. On the basis of examination andforlnveatlgation, In my opinion death occurred at
<br /> a d due to theca (e) Is
<br /> d. (SI store and Title) a 8 the lima, dale and place and due to the cause(s) stated. (Signature and Title) T
<br /> F
<br /> J 'd
<br /> 26, DIDTOBACCO U NTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION EN CONSIDERED 26b. WAS CONSENT GRANTED?
<br /> Q YES ❑ PROBABLY ❑ UNKNOWN ❑ YES fa 0 Not Applicable if 26a is No ❑ YES Ie NO
<br /> 27, NAME, TITLE NDADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (TypoorPnnl)
<br /> Ryan Crouch, D.O. 800 Alpha St., Grand Island Nebraska 68803
<br /> 28a. REGISTRAR's SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr,)
<br /> N. JUN 2 9 2007
<br />
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