|
STATE OF NEBRASKA
<br />WHEIU THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF �
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEI
<br />8c. CITY OR TOWN
<br />Grand Island
<br />HUMA'N SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY �`Of� V7�4� �''� �:i�• s� e_� �'�
<br />DATE OF ISSUANCE ^ � '�� � a
<br />!����� � ��:.� � �
<br />01 /28/2011 S�"'4WL��' : P ���S p �', >'
<br />AS�'�T9/��T TR�IR '',
<br />D�i� �' E� �F4F.TH AltjD ,,;�
<br />i LINCOLN, NEBR.4SKA y � � .� .��`�°-� _
<br />i STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC�� ��, �� F`� �,�. �` 6 � � OOZOs
<br />CERTIFICATE OF DEATH ' >: f, �{ r � �,; � _ ._�"
<br />. DECEpEN7"S-NAME (Flrst, Middte, Last, SuHbc) 2. SIX �' "� 3. DAT,EDFDEATH (Mo., Day, Yr.)
<br />Donald ' Duane Lundqutst Male January 98, 2011
<br />. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF B1RTH 5a. AGE - Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y►s•} MOS. DAY3 HOURS MIN3.
<br />Hamilton County, Nebraska 91 August 4, 1919
<br />. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />50&12 HOSPITAL � InpaUeM O_ THER ❑ Nursi� Home/LTC � Hosplce Faclitty
<br />b. FACILITY•NAME (N not Institution, give atreet and rwmber)
<br />❑ ERfOutpaUent � DecederR's Home
<br />Saint Francis Medical Center ❑ oon ❑ Other(Specify
<br />c. CIT'Y OR 1'OWN OF DEATH pnctude Zip Codej 8d. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />�
<br />O
<br />�
<br />�a
<br />O
<br />�
<br />z
<br />t�L
<br />.b'
<br />�
<br />€
<br />�
<br />a
<br />�
<br />�
<br />�°-
<br />eb. COUNTY
<br />Halt
<br />d. STREET AND NUMBER 88. APT. NO. 8f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />2223 West 16th St. 68803 � rES ❑ No
<br />Oa. MARITAL!STATUS AT TIME OF DEATH � Married ❑ Never Marci� 10b. NAME OF SPOUSE (First, Mlddie, Last, Sufflu) Itwife, give rt�iden name
<br />❑ n�mea, n�r ��►�c.a ❑ vuiaowaa p owo�a ❑ u�k�� q�ma Desoe '
<br />1. FATHER'S+NAME (First, Mlddie, Last, Suffix) 12. MOTHER'S-NAME (Ftrst, Middle, MWiden Sumame)
<br />Oscar A Lundqulst Eva Anderson
<br />3. EVER IN U�S. ARMED FORCES9 Give dates of service H Yes. 14a. INFORMANT•NAME 74b. RELATIONSHIP TO DECEDENT
<br />(Yea, No, or unk.) Yes 08/25/1936-08/13/1946 AI a Lundquist Wife
<br />5. METHOD pF DISPOSITION 16a. EMBALMERSIC3NATURE 16b. LICENSE NO. 78c. DATE (MO., Day, Yr.)
<br />❑ Bur�al ❑ pormdon Chris McCo
<br />Y 1191 January 23, 2011
<br />� Cremation 0 EntombmerR 18d. CEMEfERY, CREMATORY OR THER LOCATION CffY / TOWN STATE
<br />❑ Removal ❑ Other (Specffy)
<br />Central Nebraska Cremati n Services Gibbon Nebraska
<br />7a. FUNERAL HOME NAME AND MAILING ADDRE3S (SVeet, Clty or Town State) 17b. 21p Code
<br />Apfel Furteral Home, 1123 W. 2nd, Grand Istand, Nebrasl�a 68801
<br />8. PAR7' 1. Frrter the chaln oi eveMe��dl�asea, inJuries, or eompllcaqons•that directly ce d the death. DO NOT eMer terminat evente such ae cardiac erreat,
<br />�plraWry �rtest, or ve�iwlar flbr111aUon wkhout ehowing the etiolagy. DO NOT BREVIATE. Frrter oniy o�re cause on a Iine. Add addidonal 0�rea U�receasary.
<br />IMMEDIATE CAUSE:
<br />IMEAEDIATE CAWSE (Flnal a) Pneumonia
<br />dlaease or condrdon reaultlng
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sepuw�da11y11s6conditlans,iT b)ChronlcObstructivePulmonarKDi ease
<br />airy. leadlne tc t1re eausa Iialed
<br />on nna a. DUE TO.OR AS A CONSEQUENCE OF:
<br />EMartlre UNDERLYINO CAUSH C �
<br />(tlieease orinjurythatinitlated
<br />the eveMe reaulUng in daatn) DUE TO� OR AS A CONSEQUENCE OF:
<br />� d)
<br />�
<br />� r ;; � ;_��� -
<br />� , �� � : �, � :.
<br />y`� ' ��Q���,�'� �i�"�� � ::
<br />�. PART II.OTHER SIGNIFlCANT CONDITIONS-Conditions co�rtribufJng to the death but not resultlng In the umleriytng cause given in PART 1. 18. WAS MEDICAL EXANONER
<br />Cardiomyopathy With Chronic Systolic CHF OR CORONER CONTACTEDI
<br />❑ ves � No
<br />1. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />❑ Na n�e�sm wnnu� t ,� �. � r�w�i � Homidde � om�.rov��sor
<br />� Pregnant et tlm9 of tleath � Acclderrt � Pandlne lm�estt9aflon ❑ P�"98� � YES � NO
<br />� Na pre¢nane, bu� pre¢nene w��n a� aays or aeam � peaesman 21d. WERE AUTOPSY FlNDINGS AVAILA
<br />� swdae � could na ne deoermurea TO COMPI.ETE CAUSE OF DEATHT
<br />❑ NM P+89�8M, but BreB�trt 0.9 days W 1 Year befow death � Other (SP�KY)
<br />� Ualmown It P�� �In the past year ❑ YES � NO
<br />!a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, famy street, factory, oHlce bWiding, corretrucdon site, etc. (Specify)
<br />z
<br />W
<br />li.
<br />�
<br />t�
<br />'�
<br />a
<br />E
<br />.�
<br />F�
<br />INJURY AT WORK? I22e. DESCRIBE HOW WJURY OCCURRED
<br />❑ YES ❑ NO
<br />LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITY/TOWN
<br />23a. IDATE OF DEATH (Mo., Day, Yr.)
<br />� January 18, 2011
<br />� } 23b. y ATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Z anua 19, 2011 06:57 PM
<br />� � 3d. Tb die best oi my Imowiedge. death ocwrred at the 8me. date and pla�
<br />� atid Gue W the cause(s) afated. (Slgnature and 79tle)
<br />$ Travis S. Hageman, MD
<br />STATE
<br />APPROXIMATEINTERVAL
<br />o�wet to death
<br />Days
<br />onsetto death
<br />Years
<br />onsetto death
<br />or�et to death
<br />ZIP CODE
<br />��� 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />� �� Y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAI
<br />na�
<br />s���
<br />� � 24e. On the basie M axaMnaGon enNor invastlgation, in my opinion death axurted at
<br />F o $ the Ume, date and place end due to the wtwe(s) atatad. (Signature and TWe)
<br />c, °
<br />YES .0 NO U PROBABLY ❑ UNKNOWN I❑ NES Q NO
<br />..._. .. _ ._.y_.� ..,........�..�. ..... � ��v�
<br />Travis S� Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />NotApplicable H26a Is NO fl YES I I NO
<br />28b. DATE FlLED BY REGISTRAR (MO., Day, Yr.)
<br />January 24, 2011
<br />
|