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� STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTl-1 AI�D' Hly�1AA1�.SERVICES, IT CERTIFIES;
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASitA (s?�l��ll��T z O�;;HEALTH AND
<br />� HUMAN SERVICES, VITAL RECORDS OFF7CE, WHICH IS THE LEGAL DEPOSITORY FOI� ,V L'� ,R� 9: �.. ?�� ,,�� ¢
<br />�',. ,� 9R� �
<br />DATE OF ISSUANCE � � s .
<br />',� w! : l, . �. �, .a
<br />S�.�L�1'� CQG?PER .- ca� ,�' ,� ��
<br />06/22/2011 � p � 2 0 i s � � �I��,L�TAAI ;� � �
<br />��P.�Ri"MENT OF HEALTH ANp, �
<br />LINCOLAI, AIEBRASKA , �;J-lU��•SE � ��� '`� + , ,
<br />� �s .; ��st.✓ .
<br />'y STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVEC+ES r , �� ' ''' � � � • � '
<br />-------- - -- -- -- --- - o r ... . . �e���` � �11 02077
<br />� ctrci iric�+►� r �r ut�►i n � - � ° � '� „+r�� •� ��: �.'-" °
<br />7. DECEDENTS-NAME (FUst, Mlddie, Last, Suftix) - 2. SIX :, `��-. ,3. DATE pF-DEATH (Mo., Day, Yr.)
<br />Jeannlce Rae Plate Female June 19, 2011
<br />4. CIIY AND STATE OR TERRRORY, OR FOREIGN COUNTRY OF BIRTH 5a. AOE • Last BlRhday b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y►sd MOS. DAYS HOURS MINS.
<br />Ord, Nebraska 81 May 13,1930
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />507-30-9222 osa rns ❑ trmaueM OTHER � Nursing HomelLTC � Hospice Faetttty
<br />8b. FACILI7Y-NAME pf not I�UtuUon, give street and number) � ER/OutpatleM ❑ Decederrt's Home
<br />�
<br />� Tiffany Square Care Center ❑ noa ❑ omer;spec�ry)
<br />� 8c. CI'fY OR TOWN OF DEATH pnclude Ztp Code) 8d. COUNTY OF DFJITH
<br />o Grand Island 68803 Hall
<br />� 8a. RESIDENCESTATE 8b. COUNTY 9c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />�7 9d. STREET AND NUMBER 9e. APT. NO. 91. ZIP CODE 8g. INSIDE CITY UMITS
<br />2209 E. Stolle Park Road 68801 � v�s ❑ No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH � Martied � Never Martled 10b. NAME OF SPOU38 (First, Mlddle, Last, Suftix) If wife, give matden rmme
<br />� ❑ Menled, but separated ❑ Widowed ❑ DNorced ❑ Unknown RUtly Plate
<br />d
<br />� 11. FATHER'S-NAME (First, Middle, Last, Suftix) 72. MOTHER'S-NAME (First, Middle, Malden Sumame)
<br />Clarence Fox Cecil Mairs
<br />E 13. EVER IN U.S. ARMED FORCES? Oive dates oT servlce H Yea. 14a. INFORNUWT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ (Yes, No, or unk.► No Rudy Plate Husband
<br />,� 15. METHOD OF DISPOSITION 16a. EMBAI.MER-SIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />� � Burial ❑ DormBon
<br />Matthew T. Myers 1411 June 24, 2011
<br />❑ Crematton ❑ EMombmerrt 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removai ❑ ou�er (spec�ry> • Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Cily or Town, State) 17b. Zlp Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAU3E OF DEAT See Instructions an exam les
<br />18. PART L E�rtaz the shaln of evaMS-diseasas, Iryuries, m comptlmtlo�-that dlrectly cauwd Ure death. DO NOT eMer tenNnal everrts weh as cardiac arteat, ; APPROXIMATE INTERVAL
<br />reaplratary arrest, or ven6rlcular flbdi�atlan without showl� tlre etlolopy. DO NOT ABBREVIATE EMet oniy one cauae an a Ihre. Add eddtUOnal Ii�ree H�.
<br />�
<br />IdpNEDU►TE CAUSE: ; onset to death
<br />iMneeoure cause �� a) Respiratory Failure ;> 1 Week
<br />a�� or eondltion resum� � - -
<br />In deathl DUE TO, OR AS A CONSEQUENCE OF: i onset to death
<br />Sequemlaly list eondmons, n b)Alzheimers Dementla �> 1 Year
<br />a�ry. Ieadinp ta the cause Ileted
<br />on Iirre a. DUE TO, OR AS A CONSEQUENCE OF: { onset to death
<br />Frrter the UNDERLYINO CAUSfl ��
<br />(diseaee or In)ury that Inklated
<br />��"t ��"B �" �'� DUE TO, OFt AS A CONSEQUENCE OF: : onset to death
<br />� d)
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS-0ondiUoire contrlbutlng to the death but rrot resulGng In the u�uleriying cauae given In PART I. 18. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED7
<br />� ❑ YES � NO
<br />� 20, IF FEMAI.E: 21a, MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED9
<br />� � NotpreBnairtw(thinpastyear ��Naturel �HOMdda �DrivedOparator � �S � NO
<br />v ❑ aree�M�a� �ra�u, p n�aaM � PendinB ImeetlBaflon 0 a�"o�
<br />� � Not prepnaM, but preB�em within 42 tlays ot tleath guicitle Could not be determined ���" 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />'� � Not prepna�rt, but preB�eirt 49 daYe M 1 Year before death � � � pther (g�eCHy) TO COMPLETE CAUSE OF DEATH?
<br />� ❑ Unlmown it Pre9nant withln the Past yea�' ❑ YES ❑ NO
<br />� 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. 71ME OF INJURY 22c. PLACE OF INJURY•At home, farm, etreet, factory, oftlee bullding, construcUon site, etc. (Speci(y)
<br />�
<br />� 22d. INJURY AT WORK1 22e. DESCWBE HOW INJURY OCGURRED
<br />F�-
<br />� YES ❑ NO
<br />22f. LOCATION OF tNJURY - STREET 8 NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo.. Day, Yr.) ' 24a. DATE SIGNED (Mo.. Day, Yr.Z 24k. TI�lIE 4EDEATH _ _
<br />� � ' June 19, 2071 ` � � �
<br />� } 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ��� y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� o June 20, 2011 10:10 PM g d<�
<br />Sd. To the best M my Imowled8e, death occurted at the W�re, dete end place $��� yqe, p� trye baeia oT eaaminadon anNor Inveatigadon, ln my opinlon tleath occurred et
<br />Wre
<br />� and due to tha cauee(e) stated. (SlqnaNre antl TIUe) � � the Ume, tlate and placa and tlue to tlre cauee(e) stated. (Slpnature and Tltie)
<br />'" Jennifer L. Brown, MD ~ g s
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? x8a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO NotApplleable H28a Is NO ❑ YES ❑ NO
<br />2. , TITLE D R F P I 1 T , R PH I A {fype or Print
<br />Jenn(fer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE 28b. DATE PILED BY REfiISTRAR {Mo, Day, Yr.)
<br />June 21, 2011
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