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ADAMS COUNTY, NE
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INST. NO.~t~ ~ O
Date ~~1~'-0~' Time ~ ~~
V
REGISTEFZ OF DEEDS
RESERVED FOR REGISTER OF DEEDS RECORDING SPACE
ADAMS COUNTY NE
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PAGE 1 OF ~ PAGES
STATE 0)E NEBRASKA °
• WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTIf AND HUMAN SERVICES
SYSTEM, IT CE/3TIFIES THE BELOW TO BEA TRUE COPY OF THE ORIGINAL RECORD ON Frl.. F WITH
' THE NEBRASKA HEALTH AND HUMAN SERVECES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~ A
DATE OF ISSUANCE (w, "~(J" ~
~IAY 0 ~ 200 TANLEY S. COOPER
".N ASSISTANT STATE REGISTRAR
LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES
STATE OFNEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT ~ ~ ~ ~ Q,
n r n r u `~-~
V IL rl 1 1 1 1 V /'1 r
1, DECEDENT'S-NAME (Flrsl, Middle, Lest, Su(Iix)
Delno L. Pedersen __ v~~~
2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
Male _ April 22, 2006
4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Last Birthday 5b. UNDER 1 YEAR 5c. UNDER t DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
. (Yrs.) MOS. DAYS HOURS MINS.
b9 June 27, 1936
Boelus, Nebraska _ _
7.SOCIALSECUflITYNUMBER 6a. PLACE OF DEATH
505-38-6837 HOSPLT91=: ~ Inpatient OTHER U Nursing HomelLTC ^Hospice Facillly
Bb. FACILITY-NAME (II not Instllulion, give slreel and number)
t
l C ^ ER/Oulpallenl CJ Decedent's Home
er
en
VA Medica
4101 Wool.woth Avenue, Omaha, NE 68105
^ Don ^Other (Specily)
Bc. CITY OR TOWN OF DEATH (Include Zip Code) ~
Omaha 68105 - 6d. COUNTY OF DEATH
Douglas _, __
9b
000NTY 9c. CITY OR TOWN
9a.RESIDENCE-STATE
Nebraska .
Adams Hastings
9e. APT. NO 91. ZIP CODE 9g. INSIDE CITY LIMITS
9d.STREETANDNUMBER 68901 ~) YES ^ No
133 East Park Street
10a. MARITAL 5 TATUS AT TIME OF DEATH ^ Mauled ^ Never Mewled 106. NAME OF SPOUSE (Flrsl, Middle, Lasl, Sullix) II wile, give maiden name.
^ Mauled, but separated ^ Widowed I~Divorced ^ Unknown
- .
11. FATHER'S-NAME (First, Middle, Lasl, Su1lix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
n
d tled8~
,
' Ofelt Pedersen Mildre
' 14b. RELATIONSHIP i0 DECEDENT
13. EVER IN U.S. ARMED FOFlCES? Give dales of service II yes. 14a.INFORMANT-NAME
(Yes, no, Drunk.) Bretle Pedersen Son
07 19/54-07/18 5. ~ _
Yes
_
15.,METHOD OF DISPOSITION I LMERSI E ~ 16b. LICENSE NO 16c. DATE (Mo., Day, Yr. )
2006
il 27
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16d: CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN 'STATE
I[~Crematlon ^ ENOmbmenl
!~ ^Removal UOlher (Specily) B-V Crema-tion Center Hastings Nebraska
[ FUNERAL HOME NAME,,^ND~MAILING ADDRESS (Street, Clly or Town, Stale) 1225 North Elm Avenue 17b. Zip Code
17a
.
ton-Butler-Vn7-land Fi.tner.al Home .Ha ones, Nebi°TSka 168901
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APPROXIMATE INTERVAL
~ 116. PART I. Enter the Ghsln of events--diseases, in)urles, or complicallons--Thal directly caused the death. DO NOT enter terminal events such as cartliac arrest, '~' f
r
,rp
; ~
or ventricular Ilbrillallon wllhoul showing the ellology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Imes II necessary. I
respiratory arrest
r,.
I;t ,
~ i onset ld death
ly;
[1: IMMEDIATE CAUSE: I
;2; iMinutes
~ IMMEDIATECAUSE(Flnal ° (a) Cardiac arrest - ,
. I onset to death
disease orcondltlon resulling DUE TO, OR ASACONSEOUENCE OF:
I
'r
~~r
f Indealh)
. . ~~ IHours
' (b) Hyperkalemia I
Sequ¢nllally list conditions, if
1 onset to death
any, leading to the cause listed DUE TO, OFl ASACONSEQUENCE OF:
1
(% on Ilne e.
Enlerthe UNDERLYING CAUSE
failure- multi-organ failure (Days
(dlseese or ln)ury that lnltloled O -
° Renal
_
_
Iheevenlsresvllinglndealh) DUE TO, OFl ASACONSEOUENCE OF: I onset to death
LAST I
I '
Id) 19. WAS MEDICAL EXAMINER
16. PAR711. OTHER SIGNIFICANT CONDITIONS-Condillons contributing to Ibe death but not resulting in the underlying cause given in PART I.
CONTACTED?
OR CORONER
yy
^ YES L_F NO
~
~,
~ 20. IF FEMALE: 21a. MANNER OF DEATH 21 b.IF TRANSPORTATION INJURY 21 c. WAS AN AUTOPSY PERFORMED?
l~Nalural ^ Homicide ^ Driver/Operator
^ Not pre,ranl wllhln past year ^ YES ~ NO
^ Passenger
,,
rf
,, ^ Pregnant al Ilme of death ^ Accldenl^ Pending Investigation
^Pedeslrian 27d. WERE AUTOPSY FINDINGS AVAILABLE TO
~:
i''"' ^ Nol pregnant, but pregnant wllhln 42 days of death ^ Suicide ^ Could not be determined U Other (Specily) ~ '
COMPLETE CAUSE OF DEATH?
7:
:.~ ^ Nol pregnant, but pregnant 43 days l01 year belore death
^ YES ^ NO
(
y' ^ Unknown II pregnant wilhln the past year _ _
,
~1~.
u., 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-AI home, farm, slreel, laclory, ollico building, conslrud.icn cite, e!c. (Specily)
m
7;r
~~, - -
22d.INJURY AT WORKI 22e. DESCRIBE HOW INJURY OCCURRED
-
- -
^ YES ^ NO _
-- '- STATE ZIP CODE
221.LOCATION OFINJURY-STFlEET&NUMBER, APT. NO. CITYftOWN
~` ~ 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
~~ ?, a. DATE OF DEATH (Mo., Day, YrJ
z
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2006 _
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PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
' i O 24c
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w ~ 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF- DEATIi .
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°aZ Aril 'L3, 2006 4:20 P. m o¢~o
opinion death occurred al
in m
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u c 23d. To the best of my knowledge, death occurred al the Ilme, dale and place
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or
u w z 24e.On the basis of examination and
dale end place and due to the cause(s) staled. (Slgnalure end Tllle)
a z p the lime
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v
o ~ end due to the cause(s) slated. (Slgnalure and Title) ~
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DIDTOBACCO USE CONTRIBUTETOTHE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
'~25
.
!' Not Applicable if 26a is NO fl YES ~1 NO '
^ YES ^ NO ^ PROBABLY ~,'I UNKNOWN ~ YES J NO _
i' 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
4101 Woolworth Ave., Omaha, NE 68105
ter
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di
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en
ca
Segen Chase, M.D., Ontaha VA Me
26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
28a. REGISTRAR'S SIGNATUFlE
MAY 0 4 2006
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