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STATE OF NEBRASKA
<br />WHEN THIS COPY C'e4RRIES THE RAISED SEAL OP THE NEBRASKA DEPARTMENI" (3� HE
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR�
<br />HUMAN SERVICES, VTTAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSI7"ORY �Q�;'
<br />DATE OF ISSUANCE , '' ��,-
<br />11 /01 /2011 ` �T�A
<br />201�003�G , ���
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<br />LINCOLN, NEBRASKA Ul�f
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERV�(
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<br />I�l� H�P'I,�SERI/iCES, IT CERTIFIES
<br />)�.�II�T�1�'�1�fT`C�F�EALTH AND
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<br />JT OF i�iEALTH fiJ�tU �'
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<br />CERTIFICATE OF DEATH '' ` �''�aY ' �' �`•�� . °
<br />1. DECEDENTS-NAME (Flrst, Mlddle, Last, Sufiz) 2._SD( :` r ` 1 S. DATE OF DEATH (Mo., Day, Yr.)
<br />Jean Lorralne Corneltus Female "�`October 20, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Btrthday b. UNDER 7 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y�•) MOS. DAYS HOURS MINS.
<br />Nysted, Nebraska 80 July 14, 1931
<br />7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />505-36-3851 �❑ �npave� OTHER ❑ Nurel� HomelLTC � Hospiee Faeitlty
<br />Bb. FACILITY-NAME �i( rrot Inetitution, gNe street and number) � ER/Outpatlerrt � Decedent's Home
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<br />� 1127 N. St. Paul Roed ❑ DOA ❑ ot�+er(spec�ry)
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<br />� Bc. CITY OR TOWN OF DEATH pnclude Zlp Code) 8d. COUNTY OF DEATH
<br />c Grand Island 68801 Hall
<br />� 9a. RESIDENCESTATE 8b. COUNTY 9c. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />� 9d. STREET AND NUMBER 9e. APT. NO. 8L ZIP CODE 8g. INSI�E CITY LIMITS
<br />�` 1127 N. St. Paul Road 68801 � res ❑ No
<br />� 10a. NUIRITAL STATUS AT TIME OF DEATH � Marrl�l ❑ Never Marrled 10b. NAME OF SPOUSE (Flrs�, Middle, Laet, SuFfiz) H wife. 81ve malden �me
<br />� ❑ neamed, but aeparated ❑ wnaowea ❑ u�vorcea ❑ unicnown ,o,rchie Comelius
<br />� 11. FATHER'S•NAME (Fhst, Middle, Last, Suffix) 12. MOTHER'&NAME (First, Middle, Malden Surr�me)
<br />� Knud Jeppesen Norma � Petersen
<br />E 19. EVER IN U.3. ARMED FORCES? GWe dates W service N Yea. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ (rea, No, or u�uc.) No Archie Comelius Husband
<br />� 15. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 18e. DATE (Mo., Day, Yr.)
<br />� � Burtal ❑ Donadon
<br />Timeree Andreasen 1390 October 25, 2011
<br />❑ Crematlon ❑ EMombmer�t 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY! TOWN STATE
<br />❑ Removal ❑ Other (SpeeHyr)
<br />Nysted Cemetery Nysted Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, Cily or Town, State) 17b. Zip Code
<br />Jacobsen-Greenway Funeral Home, 411 O Street, PO Box 112, St. Paul, Nebraska 68873
<br />CAUSE OF D TH See nstructions and exam les
<br />1B. PART 1. EMer the ghain of eveMe-dlaeasea, InJuries, or eompllmtions-that dlreefiy eaused the death. DO NOT e�rter tenNnal ewerrte sueh as cardiee arreat, : APPRO70MATE INTERVAL
<br />reeplratory art�t, or ve�mlwlar flDrllladon without ahowing the etlology. DO NOT ABBREVIATE. EMer only otre muse on a Iirrre. Add additlonal tlnea K�ry. �
<br />IM1I�VIEDIATE CAUSE: ; oreet to death
<br />IIdMEDIATE CAUSE (Flnal e) Metastatic Cervipl Cancer ; Years
<br />dleease ar condttlon reauitlng
<br />��� DUE TO, OR AS A CONSEQUENCE OF: : o�et to death
<br />8equerrtlaily Ilst eonmtlona, H tl�
<br />enY. leadinp to fhe cauee IleteU
<br />on Itrre a DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />EMer tha UNDERLYINO CAUSE C �
<br />(dieease or Iryu�Y that initlated
<br />fhe eveMe resultine in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />usT d)
<br />1H. PART II.OTHER SIGMFICANT CONDITIONS�o�itlo� conMbutl� to the death but rwt resulUng in the ur�deriying quse given In PART 1. 19. WAS MEDICAL EXAMINER
<br />Mycosis Fungoides, Coronary Artery Disease, Anemia, Renal Insufflciency OR CORONER CONTACTED?
<br />� ❑ ves � No
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />� � NM pregnant within past year � NaWrel � Homlcide � DrlvedOperaMr
<br />, Prepnant at Ume of tleath ���� ❑ 1'ES � NO
<br />V ❑ � AccldeM � PendlnB ��BStIBaUon
<br />� ❑ Noe aree�. buc o�ee��u �� dere a aee�n � pedeat�an 21 d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />� Suiclde � Coultl nM be determi�retl TO COMPLETE CAUSE OF DEATH?
<br />� � Not P�9�R but piegnaM 49 tlays to 1 yeaz betore death � Other (gPBCI�N)
<br />d � u��o,� rc a�a�ent wmm� ure a� rear
<br />� YES ❑ NO
<br />a 22a. DATE OF INJURY (Mo., Day, Yr.) 226. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, atreet, tactory, office bulldi�, co�tructlon site, etc. (SpecHy)
<br />E
<br />$
<br />� 22d. INJURY AT WORK7 22e. DESCWBE HOW INJURY OCCURRED
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<br />❑ YES ❑ NO
<br />22t. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />23a. DATE QF DEb1TH (Mo., Day, Yr�� - 24a: DATf 81GNED (Mo:; Day, YY.) z4b. TtIfAE OF DEATH
<br />� � October 20, 2011 � � �
<br />�, �� 23b. DATE SIGNED (Mo„ Day, Yr:) 23c. TIME OF DEATH �� k 24c. PRONOUNCED DEAD (Mo„ Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />p � Z October 25, 2011 11:00 AM � d<�
<br />$� � . To the 6eet ot my knowledBe. deatb oaurted at She tl�. tlate aml placa $� � yqe. On the basla oT exeminetlon enNor Inveetlpatlon. in my oPinlon death aceurred et
<br />�- and tlue to the eauae(s) statetl. (8ipnature end Tltle) �� me nme. aate ana ptace ana aue co ure muee(s) emtea. (siynawre ana ntte)
<br />~� Jane A. McDonald, MD ~ g s
<br />2S. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED9 26b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UMWOWN ❑ YE9 � NO NotApplieable H28a ta NO ❑ YES ❑ NO
<br />27. NAM TITLE D AD R ER (PHY 1 , HY 1 I TAN , R NER TY ype O� PMrrt
<br />Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 688U3
<br />28a. REGISTRAR'3 SIGNATURE � 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />October 27, 2011
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