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STATE'OF NEBRASKA Z `� `� � y � ��
<br />WHEN THIS COPY CARRIES THE RAISED S�'AL OF THE NEBRASKA HEALTH AND HUMAIV SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY QF THE OR1G/NAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECT/OAI, WHICH IS
<br />THE LEGAL DEPOSITORY FOFt VITAL REC[iRDS. ��,r ;�, �
<br />DATE OF ISSUANCE �� _
<br />"L '� t� st
<br />01/31/2008 - �� ���"�
<br />as3�sr.�' .�'��+���s�i�r
<br />LINCOLN, NEBRASKA HEAtAFFAi'YD�U� S�f��1!!L'�.�5
<br />STATE OF NEBRASKA�- QEPARTJNENI OF HEA�,TH AND HUMAN SE �£ � �_�=�_ ��,_�030$ __-.
<br />CERTIFIC�►TE OF DEATH - ��,��- --: .�_= , =--
<br />1. DECEDE S-NAME (Flrst, Middle, Last, Suffix) 2. S� . �• 3. DATE Q�D€AT}((Mo; Day, Yr.)
<br />Roy thias Lorenzen �llaf� "�;"`°`� - ... ,ta�ya12=70Q7�= °
<br />4. CITY TATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last Birthday b. UNDER 1 YEAR �,;,�F! �1'Did1P , �$�UAI@,�QF BIR'YH (Mo; Day, Yr.)-
<br />(�'�•) MOS. DAYS HOU 5. 3 F ��< '
<br />Grand I and, Nebraska 82 ° � April'26 1925
<br />7. SOCUIL URITY NUMBER 8a. PLACE OF DEATH
<br />506-22 753 OSH PITAI. ❑ InpaUeM OTHER � Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACI NAME pf not Instltutlon, give atreet and number) ❑ ER/OutpaUe� ❑ DecedeM's Home
<br />�
<br />� Grand I and Veterans Home ❑ non ❑ Other (Specify)
<br />�
<br />� 8C. CITY O OWN OF DEATH pnclude Zlp Code) Bd. COUNTY OF DEATH
<br />o Grand I land 68803 Hall
<br />� 9a,. RESIDE ESTATE 8b. COUNTY 8c. CITY OR TOWN
<br />w Nebras Hall Grand Island
<br />� ed. STRE D NUMBER 9e. APT. NO. 8L ZIP CODE 8g. INSIDE CITY LIMITS
<br />T 2309 5th 68803 � res ❑ No
<br />� 10a. MARIT STATUS AT TIME OF DEATH � Marrfed ❑ Plever Ma►ried 10b. NAME OF SPOUSE (First, Middle, Last, Sufflx) IT wife, 8�e maiden �me
<br />� ❑ nnem , b�t Sa��caa ❑ wm�ed ❑ o�or�aa ❑ ur��ow� Enid Dutton
<br />�
<br />11. FATHE NAME (First, Middie, Last, SuHlx) 12. MOTHER'S-NAME (First, Mlddle, Maiden Sumame)
<br />m John Lorenzen Hermina Untight
<br />Q ' 13. EVER IN S. ARMED FORCES? C�ive dates ot service N Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />S
<br />$ (res, No, r unk.) Yes 08/17/1943-04/02/1946 Enid Lorenzen Wife
<br />,� 7S. METHO F DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F ❑ suna� ❑ oo�eon Not Embalmed July 13, 2007
<br />� Cre on ❑ ErRombment qgd. CEMEfERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Remo i❑ ower (speciry� W��awn Memorial Park Grand Island Nebraska
<br />17a. FUNE HOME NAME AND MAILING ADDRESS {Strest, Clty or Town, State) 17b. Zip Code
<br />Livings n-SondeRnann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 68803
<br />C U5� F EA7 ee instructions an exam es
<br />18. PART 1. rthe chaln of eveMa� dieeases, iryurtee, or compUCatlonsdhat dlreWy cauaed tha death. DO NOT eirter terminal eveMe such as cardiac arreat, ; APPROXIMATE INTERVAL
<br />reapt arrest, or veMAcutar flbriliation withart ahowing the etloiogy. DO NOT ABBREVIATE. BMer onfy one puae on a Iine. Add addRlonal Mae tt neceaeary.
<br />IMMEDIATE CAUSE: ; onset to death
<br />U11�MEDIATE se��� a)Aspiration Pneumonia ; 2 Weeks
<br />tlleease or tlitlon resuldng
<br />�° d �'� DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />s�n�a„ue�y ��ewo„e, e b) Dementia, Alzheimers E> 1 Yr
<br />8rty. leading Ure eause Ilatad
<br />on Iine a DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />EMer the UN � RLYINO CAUSE ��
<br />(disease or l J ry H�at intdated �
<br />� 018 "� �" �'� DUE TQ OR AS A CONSEQUENCE OF: � onset to death
<br />� d)
<br />18. PART U. THER SIGNIFICANT CONDRIONS-CorMiUons conMbuting to the death but rrot resulUng In tha underlying cause gNen In PART I. 18. WAS MEDICAL EXAMINER
<br />Chronic structive Pulmonary Disease OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />W . IF FE 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />� � Noi pre . wkhin paet year � Natural � Homiclde � DriveROperator ��S � NO
<br />U Prag at tlrtre of death � Passenger
<br />❑ � Acdde�rt � Pentling inyeatl8atlon
<br />� Na pre bu� pre¢nan[ wnhin az aays w deam � PedesMan 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />a [� Suiclde � Cou�tl not ba determined TO COMPLETE CAUSE OF DEATH?
<br />� Not pre but preBnaM 49 days M 1 year befora deatM1 � Dther (SP�b) �
<br />� � Unlm Hpregnantwkhlnttrepastyear . ❑ YES ❑ NO �
<br />°' 22a. DATE INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, offlce bullding, cor�tructton site, etc. (Spec(fy�
<br />E
<br />$
<br />� 22d. INJUR T WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />� � � Np
<br />22L LOCA N OF INJURY - STREET 8� NUMBER, APT.NO. CITYlTOWN STATE ZIP CODE
<br />� 2' DATE OF DEATH (Mo., Day, Yr.) �_ 24a. DATE�GNED j�,pay, YL•) ,___ 246. TIMEDF QFATH___. _ ---_-
<br />b� � July 12, 2007 .� �
<br />�' a', � 2 DATE SIGNED (MO., Day, Yr.) 23c. TIME OF DEATH ��� y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />�� Z JUI 13, 2007 07:10 PM a a a �
<br />E� �
<br />c � To the best ot my Imowledge. tleath occurred at the tlme. date and place $ W� 24e. On the baels M exam�natlon antl/or Imreatigalion. ln my opWOn death occurted at
<br />��� � and tlue W the cauae(s) etaled. (Signature and Tkle) � �� �& p the dme, date and place antl tlue W Ure ceuse(e) sletetl. (SlBnature and Tkle)
<br />'" a nnifer King, MD ~ g s
<br />2. DID TO CCO USE CONTWBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED7
<br />� YE � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applicable tf 28a Is NO ❑ YES ❑ NO
<br />27. D ADD OF CERT FI HYSIC , O E P SIC OR OU A ORN (Type or Pd )
<br />Jenni King, MD, 2300 West Capital Avenue, Grand Island, Nebraska, 68803
<br />28a. REGIS 'S SIGNATURE /�' � 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />fs July 13, 2007
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