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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND-HlIA4AN SERVIC�
<br />t. DECEDENT'S•NAME (Flrai, Mlddle, Lest
<br />John Raymond Gunderson
<br />4. CITY AND 9TATE OR TEARITORY, OR FOREI6N COUIdTRY OF BIRTH
<br />Cloquet, Minnesota
<br />SYSTEM, IT CERTIF/ES THE BELOW TO BE A TRUE COPY OF THE ORtG/NAL�CD�' dN1�LE Wf'Ffl �;;
<br />TWE N�BRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI�lC�-SE�TT/D15�-�AtA�H 1�'
<br />THE LEGAL DEPOSITORY FOR V1TAL RECORDS. __ �
<br />DATE OF ISSUANCE ���� � .
<br />n r 5% : -�l1QPE�.
<br />- �2
<br />AS�/�STAT� ftEG�#14�i
<br />LINCOLN, A 2 O�, �, � 5 � L� O HEA�H AiV#�lEJM`A�T�7Vl�'S
<br />STATE OF NEBRASKA- DEPARTMEMT OF HEALTH AND HUMAN SERVICES FINANCE FtI�$ SUPPORF
<br />7. SOCIAL SECURITY NUMBFA
<br />473-22-5526
<br />8b. FACILITY-NAME (If not Inatliution, give street and number)
<br />St. Elizabeth's
<br />8a CI1Y OR TOWN OF DEATH (Include Zlp Code)
<br />Lincoln 68510
<br />8a. RESIDENCESTATE 9b. COUMY
<br />Nebraska Hall
<br />9d.STREETANDNUMBER
<br />29 Kuester Lake
<br />10a. MARRAL STA1'US ATTIME OF DEATH �l�Married �❑ Never Marrled
<br />❑ MaMed, but separated ❑ Widowed ❑ Dfvorced ❑ Unknown
<br />❑ Removal ❑ Other (SpecHy)
<br />Lincoln Memorial Crematory, Lincoln, Nebraska
<br />17a. FUNERAL HOME NAME AND MAILINa ADDRESS (Streei, Ciry orTown, Stete) 178. Zip Code
<br />Lin.coln Memorial Funeral Home, 6800 S. 14th St., Lineoln, Nebraska 68512
<br />I a,x1 indealh)
<br />I �� � SequeMteRyllateonditfona,M ro� J�" ��/�i
<br />" e�ry,leadingtothecauaellated DUETO,ORA3ACON5!
<br />i on line a
<br />' r ` EirterfheUNOERLYINOCAUSE
<br />} - (dlseaseorin�urythetlnitlated ���
<br />;1 theeve"tsrea�IdnB�°deaN� DUETO,ORASACON3E
<br />��:_�'..<.:�' WS! . .
<br />OF:
<br />11. FATHER'S-NAME (First, , Mlddle, Leat, 8uffix) 12. MOTHER'8-NAME (Firat, Mlddle, Maiden Surneme)
<br />Arthur Gunderson Thera Redlund
<br />13. EVER 1N U.S. ARMED FORCES?'�Ive dfltea of aervice if yes. 14a. INFORMANT NAME 14b. RELATIONSHIP TO DECEDENT
<br />�ras,�o,orunk.)Yes Unknown Carol Gunderson Wife
<br />16. METHOD OP DI3POSITION 16a EMBALMER•SIGNATURE 166. UCENSE N0. 16c. DATE ('Mo., Day, Yr. )
<br />❑BUrlal ❑Donellon Not Embalmed December 29, 2006
<br />�remaflon ❑ Emombmenl 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY! TOWN STATE
<br />1& PARTI.Enterthechainoteventa-dfaeases,inJuriea,orcompllcetions-thatdlrectlycausedihedeath.DONOTenterterminaleventeauchescardiacerrest, � APPROXIMATEINTERVAL
<br />reapiretory arreet, or ventrlcular flbdll�tion without ahowtrre the etlology. DO NOT ABBREVIATE. Enter on(y one ceusa on e Iine. Add addi8onal Iines K neceasery. �
<br />IMMEDIATECAU6E � ansettodeath
<br />I
<br />m�rneou��cause�i � R���l �4� j2Y �i4 ! LLt/2 L ;
<br />ASeaseorconditlonr�Wting DUETO,ORASACONSEQUENCEOF: 1 ansettodeath
<br />OF:
<br />��
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS-CondiQons conVibutlng to tha death but not resulting In the underlying ceuse gitren In PART I.
<br />20. IF FEMALE: •
<br />O Not pregnant within past year
<br />❑ Pregnant at t(me of death
<br />❑ Nol pregnant, but pregnant w(ihin 42 days of death
<br />❑ Nol pregnant, but pregnent 43 days to 1 year before dealh
<br />21a.MANNEROFDEATH 27b.IFTRANSPORTAT�ON
<br />�Natural ❑ Homidde ❑ DrlvedOperetor
<br />❑ Accldent0 Panding Imrestigetion � P�erreer
<br />❑ Pedestrtan
<br />❑ Suldde ❑ Could rrot be detettnined ❑ Other (3peciry)
<br />TIFICATE OF DEATH ' Q� 3� 3
<br />, Sufflx) 2. SEX 3. RATE OF DEATH (Mo., Day, YrJ
<br />Male December 24, 2006
<br />ba. AOE-Lest Birthdey 66. UNDER 1 YEAR 6c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Dey, Yr.J
<br />(Yrs.) ]� M08. DAYS HOURS M�NS. i 'I
<br />i September 25, �929
<br />Ba. PLACE OF DEATH
<br />HOSPITAL:
<br />Ol� ❑ Nuratng HomelLTC ❑ Hospice Fedlity
<br />❑ DecedenPa Home
<br />g) InpaUent
<br />❑ ERlOUtpatleM
<br />❑ 004 ❑ mner (s�rv)
<br />Bd. COUNTY OF DEATH
<br />Lancaster
<br />8c. CITY OR TOWN
<br />Grand Island
<br />Be. APT. NO 8L ZIP CODE 8g. INSIDE CITY LIMRS
<br />68801 R] YES ❑ NO
<br />IOb. NAME OF BPOUSE (Firai, Middie, Last, Su�ix) If wife, give maiden neme.
<br />Carol Elias �
<br />�/v
<br />I
<br />i
<br />t onaettodeaih
<br />I
<br />I
<br />� onaettodeaih
<br />I
<br />�
<br />18. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED2
<br />❑ YES NO
<br />21a WAS AN AUTOPSY PERFORMED9
<br />❑ YE3 � NO
<br />21d. WERE AUTOP6Y FINDINO3 AVAIL4BLE TO
<br />g ❑ Unknown it pregnant wiihin the pastyear � _ . �-_ I ❑ YES ❑ NO
<br />L
<br />�;.' 22a. DATE OF �NJURY (Mo., Day, Yr.) � 226. TIME OF INJURY • 22c. PLACE OF INJURY-Ai homa, farm, aUeat, fectory, oHlce building, conatructlon elte, eta (Spectty)
<br />ai� r �"
<br />� �.! 22d.INJURYATWORKI 22e.DESCRI6EHOWINJURYOCCURREO ,
<br />❑ YES ❑ NO
<br />221. LOCATION OF INJURY - 8TREET & NUMBER, APL N0. CITY1fOWN
<br />23a. DATE OF DEATH (Mo.,
<br />et the tlme, date and piace
<br />mdJ�t(le ) �
<br />) 25.DIDTOBAGCOUSECONTRIBUTETOTHEDEATH? "
<br />� �./ � E��
<br />! ❑ YE3 �I.NO ❑ PROBABLY ❑ UNKNOWN
<br />� �� t+l 27.NAME,TITL ANDADDRESSOFCERTIFIER (PHYSICIAN,COI
<br />' s Lou�.s Gogela , 4740 "A"
<br />28e. REOISTRAR'S SIQNA�
<br />�
<br />� �� �� ;��,�.
<br />� J 236. DAT
<br />�°
<br />23d.To IF
<br />� end
<br />4
<br />23aTpME �
<br />28a. F�)i5'O.
<br />❑ YE9
<br />S�UE ZIPCODE
<br />��� 24a.DATESIONED(Mo.,Day,Yr.) 24b.TIMEOFDEATH m
<br />��� r 24c. PRONOUNCED DEAD (Mo., Day,Yr.J 24d. TIME PRONOUNCED DEAD
<br />8��° m
<br />24e. On the baAls of examinetlon end/or investlgatlon, in my opinlon death occurred et
<br />.� p� the time, data and place and due to the cauae(s) atated. (Signaiure and Tlfie )�
<br />~ t�i `o
<br />ORTISSUE DONATION BEEN CON3IDERED7 266. WAS CONSENT QRANTED4
<br />� NO Not Applicable H 28a la NO ❑ YES ❑ NO
<br />t �k100, Lincoln Nebraska 68510
<br />28b. DATE FlLED B� g�ST�AR�Mo�De�Yr.)
<br />A 07
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