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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH,�4A�D �IL7I�1,4Y11� S��VICES, IT C�RTIF'IES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASJ�9'1 ¢ � ` F1,t�*ML�11�T��1�I�EALTH AND
<br />HUMAN SERVIC�,S, VITAL RECORDS OFFICE, WHICH IS 7�HE LEGAL D�PO5ITORY FOR ,l�S1'`q'� REGQ�� '
<br />`' • "� r�(' ��!
<br />DAT� �F ISSUANCE � 1 �,�
<br />, �.
<br />STAI�(,.EY 5. � •; ° •. `„ f
<br />12/07/2010 2 O 10 0 9 2 3 J AS'�J�STAN �������ry�� r �
<br />DEPA�.TMEIYT OF HEAl.T!-� Al�D �, ,.. ^
<br />LINCOLN, NEBRASKA HU1�IAIV',SFR,VICf�;� ' . : ,•,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S�RVIL`�S� ^�' f� (,i f{ t^ �`". � � „:::10 �3432
<br />f�G�TICl/�ATC ftiG 1'fCA7'LJ � d ' r "• -' � �
<br />Y��� � � �Y�� � Y� '
<br />1. PECEDENT'$•NAME (Flrst, Mlddle, Lagq Sufflx) 2. SFJ( � p .� �ATE OF UEATF (Mo., �ay, Yr,)
<br />Gerald Norman Lanstrom Male �° Ndoverfrber 24, 2010
<br />4. CITY AND S7ATE OR TERRITORV, OR FOREIGN COUNTRY OF BIRTIi 5a. AGE • La�t elrthday b. UNUER 1 YEAR 5c. UNDER 1 DAY 8. DqTE OF BIRTH (MO., Dpy, Yr.)
<br />(Y�'s•) MOS. DAYS HOURS MINS.
<br />Comstock, Nebraska 78 June 10, 1932
<br />7. SQCIAL SECURfTY NUMBER 8a. PLACE OF DFJITH
<br />506-30-3523 NOSPITAL � Inpatlent QjHE6 � Nursing Homa/LTC � Flospice Faclllty
<br />8h. FACILITY-NAME (If not Instltution, glva streat and numbar) �] �Rlpu�paciarn ❑ Dacedent's Noma
<br />�
<br />� Tiffany Square Care Center Q DOA ❑ Othar (Specly)
<br />� Sc. CITY OR TOWN OF DEATN pnclude Xip Code) ed. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 8a. RESI�ENCESTATE 8A. COl1NTY 9c. CITY OR 70WN
<br />w Nebraska Hall Grend Island
<br />� 9d. STREET AND NUMeER 9e. APT. NO. 8f. ZIP CODE 9g. INSIbE CI7Y LIMIT3
<br />�, sos �. a�st st. saso� � Y� ❑ No
<br />.� 10a. MARITAL STA7U3 A7 TIME pF OEATH � Marrlad ❑ Navar Marrled 10b. NAME pF SPOUSE (Fin; Middle, Last, Suf11x) tf wNe, glva maiden name
<br />!- [� Manied, but separated ❑ wldowed ❑ �IVOrced ❑ Unknown Evelyn Darlen� Visek
<br />`a
<br />� 11. FATHER'S�NAME (Flrst, Mlddle, Last, Suffix) 12. MOTFIER'S•NAME (Flrst, Mlddle, Maidan Surname)
<br />� Joseph Lenstrom Etta Newcombe
<br />a 1S. EVER IN U.S. ARMED FORCES7 GWe dates Of serviCa HYes. 1M1a. INFORMANT-NAME 14b. RELATIQN$HIP 70 dECEDENT
<br />� �ves, No, or unk.) Yes 04/1 �3l1953-04/13/1955 Evel n parlene Lenstrom Wife
<br />� 15. METNOP OF PISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 78c. Dq7E (MO., l7ay, Yr.)
<br />F °, ❑ Burlal ❑ Donatlon
<br />Not �mbalmed November 26, 2010
<br />� Cramatlon [] Entombmant 1gd. CEMETERY, CREMA70RY OR OTHER LOCATION CITY / TOWN STATE
<br />� Removal ❑ Other (Spectfy)
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />77p. FUNERAL HpME NAME ANU MAILING APDRESS (Straa4 C�ty or 7own, SWta) 17b. Zip Coda
<br />Ail Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 688Q1
<br />F EATH ee instructions an exam es
<br />�e. PNt7 I. Enter the �n ol evsnts-�iauaaa, in)udoa, or compncat�on�ahat direcpy caussd tha drath. 00 Nor rntrr terminai vwnu �ucn a� carolac arroat, : APPROXIMATE INTERVA4
<br />resplratOry a�rost, of vsnMcular flbdlla[lon w6hout thowlnp tlla 611DIOpy. UO NOT ABBREVUTE. Entrr ony onr cauw un a IIr1a. A0A etltlR�onAI IIMa If necsasary.
<br />IMM�DIATE CAUSE: ; onsat to daath
<br />iMMeoinr� cwse �Finai a) Anoxic Encephalppathy : 13 Months
<br />dipaa� or condRlun Yrfultlnq
<br />In dwtn� pUE TO, OR AS A CONSEOUENCE OF: : onaet to death
<br />srqwmlaly lut conditlon�, if b) Myacardial Infarction : 13 Months
<br />any, Iradlny to tha ciuw Iltted
<br />on Ilns a. DU6 TO, OR AS A CONS�QUENCE OF: : onset to daath
<br />Entartna UNDENLYING CAUSE �) Gorpnary Artery Disease
<br />(tllwaw or InJury tllat InttlYtOd
<br />tha evonte neultmp In daatn� pUE TO� OR AS A GONSEQUENCE OF: : onset to daeth
<br />�,asr d)
<br />18. PART II.OTHER SIGNIFICAN7 CONDI710NS-Condltiona contrlbuting ta the death 6ut not resultinq In tha underrytng cause grvan In PART I. 18. WAS MEDICAL EXAMINER
<br />qR CORONER CONTACTED?
<br />� � YES ❑ NO
<br />� 0. IF FEMALE: 21a. MANNER OF DEATH 21d. IF TRAN$PpRTATION INJUR Ytc. WAS AN A47pPSY PERFORMED?
<br />LL
<br />� � Nqt prepnant wllhln paat yaa� � NNu�al � Nomlc�de � DrlwrlOprrator
<br />p� ❑ YES � NO
<br />U � Pnqnant at tlmr of dwth � ACCIdeM � Pandlnp InwrtlyatlDn ❑ P'�nprY
<br />� � Npt prcpnant, 6Yt preQnYYR wR11in 92 days Of dsath � Padrstrlan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />� swcida � co�ia noe ne aarorminaa TO COMP4ETE CAUSE OF DEATH7
<br />� Not proptlYnt, but preyqdllt 49 ddyi l0 1 ylar 6aforr dYath � Othrr (SprclTy)
<br />� � Unknpwn If pnpnant wBhln the pitt yee� ❑ YE$ ❑ NO
<br />°' 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At homa, farm, streat, iactary, offlca bulldinq, conetructlon alte, etc. ($peciry)
<br />E
<br />�
<br />�' 22d. INJURY AT WORKY YRa. PESCRIBE HOW INJURY OCCURRED
<br />O
<br />� ❑ YES Q NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />2Sa. DATE OF DEATN (MO., �ay, Yr.) � 24a. bATE SIGNED (Mo., Day, Yr.) 2Aq. 71ME pF DEATH
<br />� � November 24, 2p10 � �
<br />�� r YSb. �A7E SIGNED (Mo., Day, Yr.) 2ac. TIME OF bEATH ��� Y 24c. PRGNOUNGED DE4D (Mo., Day, Yr.) 24d. TIME PRONpUNCED DEAD
<br />� � Z November 26, 2010 05:30 PM � y � o
<br />r� � ]d. To tha bBit o1 my knawbdpa, dsath occurtiA N tne th11B, dita and placa � 2qe. On tha 6aala of axaminitlon anNor Inve6tlpp/lon, In my opinlon drath acculTiA at
<br />�� and tlua to tha cauae�a) staled. (Slpnaturr and 7lar) �&� the tima, date and placs and dus to e1w cauar��� nama. (Sipnature and Tltle)
<br />Rebecca Steinke, MD g o
<br />25. DID T08ACC0 USE CONTRIBUTE TO THE DEA7H7 26a. HAS ORGAN OR TISSUE DONATION BEEN CQN$IDEREU7 26h. WA5 CONSENT GRANTE�7
<br />� YE$ � NO ❑ PROBABLY ❑ UNKNOWN [] YE$ � NO Not Applica6la H 26a is NO ❑ YES � NO
<br />_ ypa or r
<br />Rebecca Steinke, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraske, 68803
<br />ZBa. REGISTRAR'$ 51GNATURE �8d. PATE FILEU 8Y REGIS7RAR (Mo., Day, Yr.)
<br />November 29, 2010
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