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STATE OF NEBRASKA
<br />WHEN THIS COPY GARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY �t�E
<br />DATE OF ISSlJANCE ,�
<br />09/15/2010 ��
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<br />LINCOLN, NEBRASKA H
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICEs� .'
<br />�tIMAN SEI2V.1'L`'ES, .IT `CERTIFIES
<br />�R!'T7�I�711T pF ,}��'ALTH AND
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<br />CERTIFICATE OF DEATFi � " -----
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<br />1. ECEDENTS•NAME (First, Middle, Last, Suffix� 2. SEX � w �, �., DATE,OF DERtH C�•� �Y� Yr.)
<br />hAarlene Avis Zersen Female �°•� :,` �'8��t�rt�bei't1, 2010
<br />4. C AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday b. UNDER 1 YEAR 6c. UNDER 1 DAY 6. DATE OP BIRTH (Mo., Day, Yr.)
<br />�B•) MOS. DAYS HOURS MINS.
<br />Chappell, Nebraska 74 October 1, 1935
<br />7• SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />524-40-5030 HOSPRAL � Inpatlerrt OTHER ❑ Nursl� Home/LTC � Hospice Faellity
<br />Bb;, FACIUTY•NAME (R not Institution, glve street aml m�mber) ER/O
<br />� ❑ utpaUent � Decederrt's Home
<br />� 2740 E. Binfleld Road ❑�A 0�(sae��'1
<br />�
<br />� 8c. CITY OR TOWN OF DEATH (Include 2ip Code) Bd. COUNTY OF DEATH
<br />o boniphan 68832 Hall
<br />� 8a; RESIDENCE�STATE 8b. COUNTY 8c. CI7Y OR TOWN
<br />w Nebraska Hatl Doniphan
<br />LL 8d; STREET AND NUMBER 8e. APT. NO. 8f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />� 2740 E. Binfleld Road 68832 ❑ rES � nto
<br />' 10a. MAWTAL STATUS AT TIME OF DEATH Q Martled ❑ Never MaRied 10b. NAME OF SPOUSE (Firat, Middle, Last, Suffix) If wHe, gNe malden rrame
<br />� nnarriea but sgparatad � Widowed ❑ oNorcea ❑ Unknown Robe�t Henry Zersen
<br />� 11, FATHER'S-NAME (Flrst, Middle, Last, Suffix) 12. MOTHER'S-NAME (Fir6t, Middle, Malden Sumame)
<br />� Clarence Lehmkuhler LaVona Berry
<br />°' 13r EVER IN U.3. ARMED FORCES7 Give dates oi service B Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEqENT
<br />$ ��res, No, or unic.) No Scott Gilbert Zersen Son
<br />,$ 15:, METHOD OF DISPOSRION 18a. EMBAIMER-SIONATURE 18b. LICENSE NO. 78c. DATE (Mo., Day, Yr.)
<br />� � sunai ❑ oonaeon Daniel D NaranJo 1071 September 16, 2010
<br />Crematlon Q Entombment �gd. CEMETERY, CREMATORY OR OTHER LOCATION CIT'Y! TOWN STATE
<br />�] Removal ❑ Other (Specity) �darview Cemetery Doniphan Nebraska
<br />171. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, CHy orTown, Stete) 17b• ZIp Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUS OF D TH See nstructlons and exam les
<br />18. pART I, Errter the tha�n of eve�rts-�dlseasea, InJuries, or compllcaUonsdhat tllrecUy causad tha death. DO N07 errter terminal eveMe auch as cerdiac errest, ; AppROXIMATE INTERVAL
<br />�� respiratory arrest, or veMNCUiar Bbrilladon without ahowing the edology. DO NOT ABBREVIATE. Farter onry oire cauae on e Iine. Add additlonal Idrea ff ne�ry.
<br />IMMEDU►TE CAUSE: ; onset to death
<br />IMdAEDIATE CAUSE (Flnal a) Acute Myocardial Infarctlon ; Immediate
<br />dl8ease or conditlan reaultlng
<br />Initleau,� DUE TO, OR AS A CONSEQUENCE OF: ' onset to death
<br />s@quarrtw�ryuatwndtuone, b)Smoke Inhalatlon : Immediate
<br />a�y, Ieading to tha quse Ilated
<br />on une a. DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />Eirter the UNDERLYINO CAUSE C �
<br />(dlaeaseorinJurythatinklatetl � . .
<br />th6 Bvente resuldng In tleath) DUE TQ OR AS A CONSEQUENCE OF: : onset to death
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<br />18;, PART II.OTHER SIGNIFICANT CONDRIONS-Conditions contributlng to the death but rrot resutUng in the underiying cause gNen In PART I. 18. WAS MEDICAL EXAMINER
<br />Coronary Artery Disease OR CORONER CONTACTED?
<br />� � YES ❑ NO
<br />W 20;7F FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />� � Not pre8� W��n past year � Naturai � Homidde � DrivedOperator ��s � No
<br />W Pregnam at dme oi tleath Pasaenger
<br />V �� � Accltle�rt � Pending Investlgatlon
<br />� � Noe pregnairt, 6ut pregnantwithin 42 days of death gulcide Could not ba tlatermined ❑ Padesulan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />❑ ❑ TO COMPLEI'E CAUSE OF DEATH?
<br />� NoL P�B�� but PregnaM 43 days W 1 Y�+before death � Other (SPediY) ❑ ❑
<br />� '�, UnlmowniipregnantwMhlnthepaslyear YES NO
<br />�' 22d. DATE OF INJURY (Mo., Day, Yr.) ZZb. TIME OF INJURY 22c. PLACE OF INJURY•At home, tarm, streat, tactory, offlce bullding, consWctton slte, etc. (Specify)
<br />E
<br />3 $eptember 11, 2010 04:00 PM Residence
<br />.� 22tl. INJURY AT WORK1 22e. DESCWBE HOW INJURY OCCURRED
<br />� attempting to extinguish grass flre with broom
<br />,, ❑ v�s p No
<br />22(. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYlfOWN STATE ZIP CODE
<br />2740 E Binfield Rd, Don(phan Nebraska 68832
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIONED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />.� ��� September 13, 2010 Approx. 04:00 PM
<br />��� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH �� k Y 24c. PRONOUNCED DEAD (MO., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />o ��< Z Se tember 11, 2010 06:08 PM
<br />3d. To the beat ot my knowletl8e, death occurred at the dme, dale and place $ �� 24e, On the basla of examination and/or imestlgadon, In my opinlon death xwrred at
<br />�'� � � and due to the puse(s) etatetl. (SlgnaWra and TttIe) �&$ Ure qmg, tlate and place and due to the cause(s) atatetl. (Slgnature and Tkle)
<br />g o Lynelle Homolka, Hall Deputy County Attomey
<br />25: DID TOBACCO U9E CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTEDT
<br />Q YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Appllcable N 26a Is NO ❑ YES ❑ NO
<br />27; TITLE D DR SS O C RT R(PHYSI 31 T, ORO H R TY A R (fype or Print)
<br />„ Lynelle Homolka, Hali Deputy County Attomey, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />28�. REGISTRAR'S SIGNATURE �� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 14, 2010
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