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STATE OF NEBRASKA � �
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH
<br />THE BELOW TO BE A TRUE COPY OF THE ORI6INAL REGORD ON FILE WITH THE NEBt2,9��
<br />HUMAN SERVICES, VITAL REGORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY F(�
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<br />DATE OF ISSIIANCE
<br />JUL 0 8 2009
<br />tINCOLN,_NEBRASKA. .
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<br />STATE OF NEBRASKA- DEPARTMENT 4F HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
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<br />Y.DECEDENT'S-NAME (First, Middle, Last, Suffix) 2.SEX ��3.DATEOEpEATH�Mo.,Dey,Yr.)
<br />Beverl Jean Jacobsen Female June 16;2Q09
<br />4. CITY AND 9TATE OR TERRITORY, OR FOREION CQUNTRY OF BIRTH Sa�. AGE-Last Birthday 56. UNDER i YEAR 5c. UNDER t DAY 8. DAT€ OF BIRTH (Mo., Day, Yr.) � •
<br />� . � (Yra.) MOS. DAYS MOURS MkNS. � -
<br />Omaha, NE. 79 November 8, 1929
<br />7. SOCIAL SECURIN NUMBER 8a. P:.RCE OF DEATH �
<br />7- 2-844 ��,: ❑ i��re�� � ❑NUrsinpHomdLTC ❑I�spkeFeciMry
<br />bD. FACILITY•NAME (If not institution, pive atreet and number) � Q ERlOutpaQent .�I DecedenfsHome
<br />1115 South Oak St. o oc� oane<<sv�u»
<br />8c. CITY OR TOWN OF DEATH (Include 2ip Coda) � . 8d. COUNTY OF DEATH . �
<br />,�rand Island 68801 Hall
<br />9a.RE31DENCE-STATE � 9b.00UN(1' � � 9c.CITYORTOWN .
<br />vebraska Ha12 Grand Island
<br />9d. STREETAND NUMBER . . � 9e. APT. NO 9f. ZIP CODE 9p. INSIDE CITY LIMITS �
<br />1115 South Oak Street 68801 � YES ❑ NO
<br />t0a. MARITAL 3TATU3 A7TIME OF DEATH �1 Married ❑ Never Married 106. NAME OF SPOUSE (FiraL Mitldle, Last, Suf(ix) It wife, pive maiden neme. �
<br />0 Meaied, but separated ❑ Widowed ❑ Divorced O Unknown � � �
<br />11. FATHER'S•NAME (First, MWdle. � Last, Suqiz) 12. MOTHEA'S-NAME (First,
<br />Lewis Andersen Alice
<br />13. EVER IN U.3. ARMED FORCES? GWe detes of service if yes. tde. INFORMANT-NAME �
<br />(ves, no, w unk.) No Jack Jacobsen
<br />75.METHODOFDISPOSIT40M � i6cEMBALMER-S16NATURE i6b.lIGENSENO.
<br />oa���ei oo�flu�, Not Embalmed
<br />�Crematbn O Entombment 18tl. CEMETERY, CREMATORY OR OTHER LOCATION CITY! TOWN
<br />❑Removal �70lher(Specify) � . . .
<br />Midtlle, Maiden Surname)
<br />Thom son
<br />� 14b. RELATIONSHIP TO DECEDENT �
<br />Son
<br />18c. DATE (Mo., Day, Yr. )
<br />June 19, 2009
<br />STATE
<br />Westlawn Cremator Grand Island NE.
<br />17a. FUNERAL HOME NAME AND MAIUNQ ADDRESS �(Street, Cily orTown, Siaie) � 17C. Zip Coda
<br />ivingston-Sondermann Funeral Home 601 N. Webb Road Grand Island, NE. 68803
<br />18. PART I. Enter tha chain of evanta-diseases, injwies, or compliceNons-•that directly aueed the�dseth. DO NOT enter terminal evenM auch as ceMiac aneel, � APPROf(IMATE� IpTfRVRI
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<br />{�'resptratory ureet, or veMricular fibrillafion without showing the eliology. 00 NOT A68REVIATE. EMer only one ceuse on a line. Atld additional linea if necessary. �
<br />� fOiMMED1ATE CAUSE: . �onset to death .
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<br />MAMEDIATECAUSE(flnel �� Natural causes associ ated wi th ol d age � unknown �
<br />d��� DUETO,OHASACONSEQUENCEOF: � �i onsetrodeath
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<br />SequaMYUy Ibt condkbm, it ro) . � . �� .
<br />��������� DUETO,ORASACON3E�UENCEOk � I onsettodeath � �
<br />onlhres . � . i
<br />EMertlisUNDIEHLYIlpCAU3E. � . .
<br />.(diwesaorin�urythetinitl�ted (°) � � �
<br />� DUETO,ORASACONSEQUENCEOP: � onsettodeath
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<br />PART il. OTHER 31GNIFICANT CONDITIONS-Contlitions contNbutMg to the death but not resulNng in Me undertying cause given in PART I.
<br />N/A
<br />20, IF FEMALE �
<br />� Not pregnent within past year
<br />❑ Pregnant at time of dsath � � �
<br />0 Not pregnant, but pregnent within 42 daqs of deeth
<br />O Nd prognant, but pregnent 43 days to i year before death
<br />❑ Unknawn if pregnant within the pest year
<br />a.MANNEROFDEATH 21b.IPTRANSPORTATiON
<br />�laturel ❑Homicide � ❑DrivedOperator
<br />❑AccWentOPendinglnvesNgadon OPe9senger
<br />O Pede�uian
<br />I
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<br />�p. WAS MEDICAI EXAMiNER
<br />OH CORONER CONTACTED7
<br />�7 YE3 ❑ NO
<br />C. WAS AN AUTOPSY PERFORMED4
<br />0 YES � NO
<br />OSuicide ❑COUWnptbedetermined d.WEflEAUTOPSYFNJDiNGSAVAILA81.ET0
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY
<br />m
<br />22d.INJURYATYJORK7 �e2e.DESCRIksEHOWINJURYOCCURREO
<br />0 YES ❑ NO
<br />221. LOCATION OF INJURV - STREET & NUMBER, APT. N0.
<br />� OOther(Specityj COMPLETECAUSEOFDEATH?
<br />❑ YES X1 NO
<br />22c. PLACE OF 4NJURKAt home, farm, street, Factory, otfice building, construction site, etc. (Specify)
<br />CIIY/TOWN
<br />� � STATE ZIP CODE
<br />23a. DATE OP DEATH (Mo., Day, Yr.) � 4e. DATE SIGNED (MO., Dey, Yr.) � 40.TIME OF DEATH
<br />�'� a�� June 30 2009 11:00
<br />�� J 23b.DATESI6NED(Mo.,Day,Yr.) 23c.TfMEOFDEATH ��4 4c.PFONOUNCEDDEAD(MO.,Day,Yc��� 4d.TIMEPRONWNCEDDEAD
<br />o m E a a� June 18 2009 6:40 m
<br />&�. � 23d. To tha best of my knowledge, death occurred at the time, tlate and plece �+ w�� e. On the basis of examinetion en / r inveatigation, in my opMion death occurred et
<br />F � and due to the cause(s) stated. tSipnature antl Tkle )♦ .� �� the ti te pl a tl to the cause(s) steted. (Signature and Title )♦
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<br />�15.DIDTOBACCO USECONTRIBUTETOTHEDEATH? 6a. HAS ORGAN OR TISSUE DONA710N BEEN CONSIDERED7 G. WAS CONSENT 6RANTED? �
<br />❑ YES ❑ NO O PROBABLY G� UNKNOWN ❑ YES C� NO Not Applicable if 26a is NO ❑ YES ❑ NO
<br />.NAME,TITLEANDADDRESSOF6ER71fIER (PHYSICIAN,CORONER'SPHYSICIANORCOUNNATTORNEY (fypeorPrinq �
<br />Martin Klein, Deputy Hall County Attorney, 231 S�. Locust St., Grand Island, NE 68801
<br />28a. REGISTRAR'S SIGNATURE � - � 28b. DATE FILED BV RECaISTRAR (MO., Day, Yr.)
<br />� ,(�. JUL 7 2009
<br />HHS-Bt 11/03(55061)
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