|
u
<br />1
<br />` STATE OF NEBRASKA ,
<br />WHEN THIS COFY CARRIES THE RAISED I SEAL'OF THE NEBRASKA DERARTMENT OF MFr4�T� A/VD H�! � � 1 AN��SE�VICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE W.TTH THE NEB�AS%FA, D,,�FA�TMENT bF HEALTH AND "
<br />HUMAhI SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOST�'ORY` FCyR �A��� R�GOR�?� �•. �� �''
<br />�,. C� � ;
<br />DATE OF.�SSUANCE I a� b � "+� '�
<br />01/27/2012 q r u; �'7`��iu�Er ,C'ooPe 1• � '�� �� " �'�.
<br />� � J. � � � � � � ..�,,• A3�I`.t�TANT 6#A'� ����(�1� `"p ,'�' � , �
<br />DERAF2`��%IE1VT Q,F HL�f#f.TH ;4/V� � >�� ' , '
<br />LINCOLN, NEBRASKA HUMAN S�RF�C�,� ,- � , ���•; „ �x .' .
<br />STATE OF NEBRASKA • DEPARTMENT OF HEAL'fH AND HUMAN SERVICES ��,*�,y ,`�� d�,�� `'� ��� �� Z 00�28
<br />CERTIFICATE OF DEATH ' t .. �, `." ' `''
<br />,. > �.
<br />. ECEDENTS-NAME', (First, dUddle, Last, 8ufPoc) 2. SIX �'� �, 3."bl1TE OF DEATH (Mo, Day, Yr.)
<br />Irene B Garrett I Female January" 22, 2012
<br />. CITY AND $TATE OR TERRITQRY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Birthday b. UNDER 1 YEAR Sc. WNDER 1 DAY 6. DATB OF BIRTH (Mo„ Day, Yr.)
<br />(Yre•) M0.R. DAYS HOUI� dtlN3.
<br />Hastings, Nebraska 89 May 5, 9922
<br />. SOCULL SECURITY NUMBER 8a. PLACE OF DEATH
<br />508-16-1430 t}�P r�t 0 tripaaeM OTHER ❑ Nural� Home/LTC � Hosplce Facllity
<br />� Saint Francis Medical Center ❑ �A ❑ �''lsa��'1
<br />� 8c. CITY OR TOWN OF DEATH (Include Zip Code) Bd. COUNTY OF DEATH
<br />o �rand Island 88803 Hall
<br />� 9a. RESIDENCE-STATH eb. COUN7Y 9c. CITY OR TOWN
<br />W Nebraska Hall Grand Island
<br />� 8d: STREBT AND NUMBER . APT. NO. 9L LP CODE 9g. INSIDE CITY UMITS
<br />622 N Edd 88801 � res ❑ No
<br />� 10�. MARITAL STATUS AT'�IME OF DEATH [] Married Q Never Mar►led' 10b. NAME OF SPOUSE (Flrst, IVliddls, Last, SuHtxl H wtte. glve emiden rreme
<br />� ❑ en���a, a�n �pa�c� p wiao� p on�or� p u��ow„ wiison Garrett
<br />� 11. FATHER'S•NAMH (Flrst, Mtddie, Leat, Suftix) 12. MOTHER'S-NAME (FUaq M�ddle, AEalden Sumame)
<br />m Aibert 9ferman Emma Koberstein
<br />E 13., EYER IN U.S. ARMED FORCH39 OWe dates ot Service H Y�.' 14a. INRORNWNT•NAM@ 14b. RELATIONSHIP TO DECEDENT
<br />$ hres, No, or unk.� No Ron Garrett Son
<br />,$ 1S. METHOD OF pISPOSiT10N 18a. EM6ALMER-SIGNATURE ' 98b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />� � eunai ❑ oo�anon Michael pavis 1189 January 25, 2012
<br />❑ Cremedon !Q Errtombmerrt 7�d. CEM6TERY; aREN1ATORY OR OTHER LOCATION CITY 1 TOWN STATE
<br />� Removai ❑ other (spec�r) ParkvleW Cemetery Hastlngs Nebraska
<br />17a; FUNERAL HOME NAME AND'MAILINO AD�RE39 (Spreet, C(ty or Town, 9tetey ' 77b. Zip Coda
<br />Llvingston-BuUer-Vqlland Funeral Home 12�5 N�Im Hastlngs Nebraska ���
<br />;
<br />� • � .
<br />C U56 F D T ee n ctians an exam les
<br />1& PAFtT 4 Fr�ter Gre �{ I�n mevems.�dlseaeas, inJurlea a eomYlleallons�Umt direWy eaueed the d�fh. DO NOT enmr tertNnal everRS euah as cmdiae arteel, � � APPROXIMATE INTERVAL
<br />reapiraro�Y ertes4 ervw�trlaulaz flbrlpabon without ehowin6 MeadOte9Y. DO NOT ABBREVIATE EMer on1Y orre �uee on a Wre. Add admdonal Wrea N �reeesemy. �
<br />IdMAEDUITE CAUSE { orreet to d�th
<br />fa�6EOU►re caus� t�� 81 Bowel Obstructlon = 24 Hours
<br />tlis$eae. or eondltion resuitlngi � �� S
<br />� 4 �� DUE TO, OR AS A CONSEQ ENCE OF: f o�t to death
<br />Bequenqaly��ateondmone,H b)IschemtcBowel � 24Hours
<br />nny, teadine to tlie cauee na�tl
<br />°O � a DUE TO, OR AS A CONSEQUENCE OF: � orreat to death
<br />E�9rthe UNDERt.YWO CAUSE � � . . . . _
<br />(d�orMJurytimllnlGated �
<br />� Ms resuld� in deatn) DUE TO, OR AS A GONSE4UENCE' OF; � or�et to death
<br />tl� .
<br />;
<br />78. qpRT II.OTHER SIONIFlCAWT CONDITIONS�Cortdklorl9 cor�trlbutlng to tFre death but rwt reaultlng In the urldarlyln8 cause 8�n in PART i. 18. WAS MEDICAL EXAMINER
<br />Advenc�d Age OR CORONER CONTACTED?
<br />� � ❑ YES � NO
<br />Z0. I FENULLE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 27c. WA8 AN AUTOPSY PERFORMED9
<br />�. . � �. q Not P�eB�wlthin P�S lreaz �,, � Nadual .,. � HmNdde� . � DNredCPeraror � YES � NO
<br />� � Pregnairt et tlme of deadf ' � AlxldeM � Pem11nB Imeatipatlon ��^�
<br />� Not prepnem, but pregaaM �rltt��n Ibs daya m aeam � Padesdian 27d. WERE AUTOPSY FlNDINGS AVAILA
<br />� [) Swctae � Cowa not ba determi�i, TO COMPLETE CAUSE OP DEATH7
<br />[� Not P�eB�rerrt, but P�aenant �0.9 Aaye W 1 Yea► batore dea� � Otlrer (BVerdry) � YES ❑ NO
<br />�, � Unimown i1 PreB�a�rt withln Gre paet year '��.
<br />E 22a;,;DATB OF INJURY {Mp., DaY, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, fartn, etreet, factory, offlce buUding, co�WcUon slte, etc. (Specify)
<br />�
<br />.S 22drINJURY AT WORK? 22e. DE9CRIBE HOW INJURY OCCURRED
<br />1�-
<br />❑ YES 0 NO
<br />22L �.00ATION OF INJURY • STREET 8 NUMQER, APT.NO. p�
<br />2Sa. DATE CF DFATH (MO., Day. Yr.)
<br />.� Jahuary 22, 2U12
<br />g Y 23b. pATE SItiNED (Mo., Day, Yr.) 23e. TIME OF DEATH
<br />, o ' Janua 24, 2012 - 12:16 PM
<br />To the beet of my WrowledBe. �ath oecurrad at the tlme� da0e arM pta
<br />�� and due to Ure Catree�s) statetl. (Slgnature and TItIe)
<br />~ �� David R. Colan, MD
<br />YE$ � NO ❑ PItOBABLY ❑ UNKNOWN
<br />IT ER IF R (P ,
<br />avid R, Colan, MD, 729 North Custer Avsnue,
<br />28a. RE(iISTRAR'S SIGNATURE�
<br />��
<br />�
<br />„
<br />ZIP CODE
<br />��� 24a. DATE SIGNED (Mq., Day, Y�.) Z4b. TIME OF DEA71i
<br />�� a � 24c. PRONOUNCED DEAD (Mo, Day, Yr.) 24d, TIME PRONOUNCED DEAI
<br />.$ � � 24e. On tlre�baeb of exeminadon enNor imeed9edon. In my opinlon death oceur�ad at
<br />$ tlte Ume. dele mM Ylaee a�M due M the �la) ateled. (SlpnaWre and Tftle)
<br />���
<br />�] ves � No
<br />R R 1
<br />Cirand Istand, Nebraska, 68803
<br />«
<br />Not ADa11C8b1e H 2881s NO ❑ YES ❑ NO
<br />28b. DATE FlLED BY RE(iiSTRAR (Mo., DaY�
<br />January 25, 2012
<br />
|