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STATE OF NEBRASKA , � '
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DFPARTMEN7 OF ME,ALT�,,-[`ANQ �J�IAl1( ,SERdl,�CES; IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEQRAS�4�, ��A�TM�JV'��?F H�A, LTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE', WHICH IS TNE LEGAL DEPOSITORY FOR �'IT� R� .,''� �`
<br />��� - ; ����`� t� .; ��
<br />,
<br />DATE OF ISSUANCE �
<br />���� ', �' �
<br />�r��r s. ��'o� � 5 � ° d �m' � }
<br />04/25/2011 � � _�`
<br />2 0110 3 8 3� As�l������-� ������ ,,�,.
<br />a��� �-��� oF H�.�z�� ��p�� .
<br />LINCOLN, NEBRASKA t•tN,�i�A ��/�l E� ��: � � r �`�"; ° ' �"�' ;
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<br />STATE OF NEBRAS CERT F CATE O DEATH uM�a�v sEa�nc�s��� ,��. ���e �?�G" �,;;�� ,��11 01302
<br />1:iDECEDENTS-NAME (Flrst, Middte, Last, Suftlx) 2. SDC ' � 3�DR�'�� �p��O�ATH (Ma:, Day, Yr.)
<br />�Rene Donald DesLaurier Male � Ap�i118; 20'F7
<br />. ITY AND S7ATE OR TERRITORY, OR FOREIGN COUNTRY QF BIRTH Sa. AGE • Wffi Birthday b. UNDER 7 YEAR 5c. UNDER 1 DAY 8. DATE OR BIRTH (Mo., Day, Yr.)
<br />(Yrs.) MOS. DAYS HOl7R3 MINS.
<br />Vermillion, South Dakota 96 July 2, 1814
<br />7. SOCUU. SECURRY NUMBER 8a. PLACE OF DEATH
<br />504 SPITA ❑ I�atient OTHER � Nursl� Home/LTC � Hosptee Facitity
<br />Bb. FACILtTY-NAME (R not Inatltution, gNe strset ansi number) � ERlOutpatierR ❑ Decede�rt's Home
<br />�
<br />� Wedgewaod Care Center ❑ noa ❑ otner �speciry�
<br />� Sc. CITY OR TOWN OF DEATH (lnclude Ztp Code) 8d. COUNTY OF DEATH
<br />o Grand Island 68803 Hail
<br />� ea. RESIDENCESTATE 9b. COUNTY 9c. CITY OR TOWN
<br />w Mebraska Hall Grand Island
<br />� 8d. STREET AND NUMBER 8e. APT. NO. 9f. ZIP CODE Sg. WSIDE CITY LIMITS
<br />�` 232 N. Waldo Av 68803 � r�s ❑ No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH � Marrled ❑ Never Marrled 10b. NAME OF SPOUSE (Flrst, Mtddle, last, SuttGc� N wfTe, giva matden rome
<br />� Q n���a but separated ❑ vinaowea ❑ Divorced ❑ Unknawn Darlene Christensen
<br />� 11. FATHER'S•NAME (First, Middle, Last, SufFlxJ 12. MOTHER'S-NAMB (Firsy Middle, Malden Surngme) c-
<br />Vetal DesLau�ier Eva Gregoire �
<br />Q ' 13. �NER IN U.S. ARMED FORCES? Ghe datea of sarvtee H Yes. 14a. iNFORMANT-NAME 14b. RELATIONSWP TO DECEDENT �`
<br />6 _
<br />$ (Yes, wo, or un�c.) Yes 10/20/1942-01/19/1943 Darlene DesLaurler Wife x
<br />� 15. I1hETHpD OF pISPOSITION 18a. EMBALMERStGNATURE 16b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />� ❑ sur�ai ❑ 000atto� Not Embalmed April 19, 2011 �±`
<br />� Crematlon [] EMombment 18d. CEMETERY, CRENIATORY OR OTHER LOCATION CITY / Tp1NN STATE _
<br />� Removal ❑ ocne� (s�wry> �ntral Nebraska Crematlon Services Gibbon Nebraska �-
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Stree4, CNy orTown, State) 17b.21p Code �
<br />Curran Funeral Chapat, 3005 S. Lacust St., Grand Island, Nebraska 68801 �
<br />CAU E OF DEA ee Instrvctions and exam les �;?
<br />1B. PART 1. EMerthe chain of averAS-�diaeeses, lnjuriea, or compllmUansBAat tlirecfly caused the deatll. DO N07 eMer termhml evema euch ea cardlac anest, � APPROXIMATE IN7ERVAL --
<br />respiratory arreat, or ventricular flbriilatlon wMhout ahowing ttre edolog�r. DD NOT ABBREVIATE E�rter only o�re eause on a Iirre. Add adtlfdonat tt�a H neoaseary. � �-�-
<br />� IMMEDIATE CAUSE: ; o�et to death �r.;
<br />iMeaeoare cnuse �� a) Alzheimers Dementia ; 5years �=.
<br />tliaea�e orcondition resutUng . ' -- --_ _- - - . . _. _ _ . . _ . . . - � - -- - -- -- .. - - . _ �..
<br />In deatti) pVE TO, OR A9 A CONSEQUENCE OF: � a�� � d� =
<br />Seque,ndalry tlet conaldona, IT b} _�_
<br />anY.lBadinB W the cause Ilslad ��:
<br />on nr�§ a. DUE TO, OR AS A CONSEQUENCE OF: ; ortset to death -.
<br />EMer ihe UNDERLYINO GAUSE �� �
<br />(dlsaese of Mjury thffi Initlet�l --
<br />Um eveme resuitlng In death) DUE TO, OR AS A CONSEQUENCE OF: � onset to death -
<br />u►sr d � '
<br />18. PAFiT II.OTHER SIGNiFlCANT CONDITIONS�CorMitiorre contributing to the death but not resultlng In the underlyi� cause ghren in PART L 19. WAS MEDICAL EXAMINER �'
<br />Atrial FibrillaUon, OR CORONER CO N TACTE D?
<br />�
<br />❑ rES � No
<br />w 20. IF FEPAALE: 21a. MANNER OF DFATH 21b. IF TRANSPORTAT70N INJUR 21c. WAS AN AUTOPSY PERFORMED4
<br />a � NotP�e9��rtwltbin P�I� � NaWcet � HomlGtle � DrNatlOperaWr �� � NO .:
<br />v p�e� � nnre or a�w � awae� [] aana�a �nY�e�+on ❑ a��ea� ��^
<br />R � Nat pregnmrc, but prepnem within 42 days oi death s���� �Wtl na be determUred � p�� 21d. WERE AUTOPSY FlNDINGS AYA�LABLE
<br />� Nqt pregnaM, but pragnarrt 49 daYe bu 1 year batare tleath � � � p�� �gp��ry� TO COMPIETE CAUSE OF DEATH?
<br />� � Unlmorm N P��t wiU»in the P� Year I❑ YE5 ❑ NO
<br />� 22a. DAtE OF IN,IURY (Mo., day, Yr.� 22b. TIMH OF INJURY 22c. PLACE OF INJURY•At home, farm, streat, tactory, offlce buliding, cor�trucdon alte, etc. (SpecHy)
<br />$
<br />� Z2d. INJURY AT WORK4 22e. DESCWBE HOW INJllRY OCCURRED � �;
<br />I�-
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo, Day, Yr.) 24a. DATE SIGMED (Mo„ Day, Yr.} 24b. TIME OF DEATH = ti
<br />, _ _._.-,_- - , :- ___ ,
<br />a � _ April 1�, 2011 .�� _, -
<br />--° - - . _ _ _-
<br />��} 2 3 b. D A T E S I G N E D ( M o., D a y, Y r.) 2 3 c. T I M E OF D F A T H ���� 24c. PRONOUNCED DEAD ( Mo., Da y, Yr.j 24d. TIME PRONOUNCED DEAD
<br />�„ Z rll 19, 2011 05:22 PM � d¢
<br />$� 0 . To ffie be81 ot my Imowled8e. deaM oc�rred ffi fhe dma. date antl place $� � 24e. On Ne bas)s W exambmtlon artWOr imeatlgadon, ln my opinton deafh occurted at
<br />� A and due to Ufa cause(s) aFated. (SlgnaWre and TIf1e) 8� � tlre tlme. date and p1aCe and due M the eause(s) atated. (SlgrreWre and THlel
<br />~� La r ry L. Hansen, MD ~ g 6
<br />2S. DID TpBACCO USE CONTRIBUTE TO THE DEATH? 26a. HA8 ORCiAN OR TIS9UE DONATION BEEN CpNSIDERED? 26b. WAS CONSEN7 GRANTED7
<br />❑ YES � MQ ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO NotAppllcable Ii26a Is NO ❑ YES ❑ NO
<br />2. AND D F RTIFIER ( I 1 T, OR ER P R U ORN ype or Prirn)
<br />Larry L. Hansen, MD, 3016 West Faidley, Grand Island, Nebraska, 68803 `.-
<br />28a. REt418TRAR'3 SIGNATURE 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />, April 21, 2011
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