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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTM:AND V IUMAN,SE{tVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA ��PA,�t7',(+1 AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITA�: RF�k�S ,'"�� ,� ��� '
<br />;w � �� f , . /�.
<br />DATE OF ISSUANCE -, � � ' ��, " �,�^,
<br />11 /16/2010 ����4.� Got�P� � 3
<br />'�,, .
<br />� �± assr��r s��r � . �� � ,,^
<br />� O � � O � O � V DEP.4`RTI�IEJVt' � fiLa��U�91,UD . ��, ;'�
<br />LINCOLN, NEBRASKA HUMA'N � ' _ r`� �'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE$ a�N` ���� �r`-�` t.�=e��`��' �• �'� �03268
<br />ctrciiric�►�t�rur�►�M •� ���,-•,•.:�-�.:,.�,:�°..:
<br />1. DECEDEPIT'3-NAME (Flrsf, Mlddle, Laef, Sufftx) 2. SEX . � 3. ����F'�QEA�H jMo� Day, Yr.)
<br />Robert Dean Foreman Male' � � Nove�nbe_r 9;�2010'
<br />4. Cf7'Y AND STATE OR TERRRORY, OR FOREIGN COUNTRY OF BIRTH Sa. AOE • Last Blrthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, YrJ
<br />(Nre•) MOS. DAYS HOURS M1NS. ; '
<br />Petersburg, Nebraska 84 August 5, 1926 '
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />'`^�43-22-7240 os PITAL � tr�aatient OTHER ❑ Nwsing HomeILTC � Hoaplee Faclllly
<br />86. fACILITY-NAME pf not Institutlon, give street and rwmber) � ER/QutpaUent ❑ Decedarrt's Home
<br />�
<br />� Saint Francis Medical Center ❑�A ❑��(sP�KY)
<br />� 8c. CPfY OR TOWN OF DEATH (include Zip Code) Bd. COUNIY OF DEATH
<br />c Grand Island 88803 Hall
<br />� 8a. RESIDENCESTATE 8b. COUNTY 8c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL 8d. STREET AND NUMBER 9e. APT. N0. 8L ZIP CODE 9g. INSIDE CITY LIMITS
<br />� 203 West 17th Street 68803 � res ❑.No
<br />' 10a. MARITAL STATUS AT TIME OF DEATH � Marrted ❑ Neve� Manied .70b. NAME OF SPOUSE (Firat, Middle, Last, Suftlx) B wlfe; glve malden �me
<br />�
<br />� [] �mea, n� $e�►��a ❑ vnaowaa p owo►�aa ❑ Unknown Geraldine L Oyster
<br />� 11. �'ATHER'S-NAME (Flrst, Middle, Last, 3uHi�c) 12. MOTHER'S•NAME (Flrst, Middle, Nlalden Sumame)
<br />m Lefghton Foreman 5r Catherine S(evera
<br />d ' 13. �VER IN U.S. ARMED FORCES? Gtve dates of service H Yes. 14a, INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />$ �ree, No, or unk.) Yes 02/17/1945-07/26/1946 Geraldine L Foreman Spouse
<br />,$ 15. METHOD OF DISPOSRION 16a. EMBALMERSIGNATURE 18b. LICENSE NO. 78c. DATE (Mo„ Day, Yr.)
<br />F � sunai ❑ no�aon Daniel D Naranjo 1071 Novembar 13, 2010
<br />Q CremaUon ❑ Errtombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Q Removal ❑ Other (SP�KY)
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State) 77b. Zlp Coda
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEA7H See Instructlons and exam les
<br />18. PART L EMer the shain oteve�diseasea, InJuriea, or complieadons-tM1at dheetiy caused the death. DO NOT eMerterminal evame such ae eardlae arrest, ; APPROXIAAATE WTERVAL
<br />respiratory ertast, or veMriwtar flbHUatlon wlthout showing the e9ology. DO NOT ABBREYIATE EMer oNy nne aause oa e 16re. Add additlonal Ihrea H �recesaery.
<br />IMMm1ATE CAUSE: ; o�et to death
<br />@AMEDIATE GWSE (Flnal a) Acute Respiratory Failure ; Days
<br />dlaease m eondidon resultlng
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: ; anset to death
<br />say�m�ty i�e ��amo�, n b) Acute Renal Failure � Days
<br />eny. �aame w me �e asma
<br />on Urre a DUE TO, OR AS A CONSEQUENCE OF: 7 o�et W deatF�
<br />E�rterthe UNDERLYINp CAUSE �1 Fallure To Thrive ; Months
<br />(disease or InJwy that InWated
<br />the eveMs resulUne In death) DUE TO, OR AS A CONSEQUENCE OF: : or�et to death
<br />� d)Dementia � Years
<br />18, pART 0. OTHER SIGNIFlCANT CONDITIONS-Condidorre corrtributt� M the death but rrot resulUrtg In the umiertying quse gWen In PART 1. 18. WAS MEDICAL EXAMINER
<br />Melanoma and MulUpie skin CA With Ongping Surveillance and removal, H/o Rectal CA, Hypothyroid, Spfnal Stenosis, OR CORONER CONTACTEDT
<br />� Hyponatremfa, (chronic), BPH, HTN ❑ vES � No
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSpORTATION INJU 21c. WAS AN AUTOPSY PERFORMED?
<br />F � NotPreB�aMwithinpastyear � NBWwI � HomlWde � D�fveAOperator
<br />� � PregneM et dme of death. ,� A�tleM � Pending InveatlgaGod ❑ P��Ber ❑�S � NO
<br />� [� Not pree�, but preg�nt wtthm 42 tlays ot deati� � Pedeabian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />� O Not pregnant, but pregnant G3 daye to 1 year betore death ❑$'�dae � Could not be.deWrminetl � g� TO CpMPLETE CAUSE OF DEA7H?
<br />( Pe bl
<br />� � Unknown it pregna�rt wlthin the past year . �❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.j 22b. 7IME OF INJURY 22c. PLACE OF INJURY•At home, farm, atreet, factory, oftice buliding, constructlon slte, etc. (SpecHy)
<br />$
<br />.� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />❑ ves ❑ No
<br />22f. LOCAT10N OF INJURY - STREET & NUMBER APT.NO. CITYlTOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIONED (MO., Day, Yr.) 24b. TIME OF DEATH
<br />.� November 9, 2010 S � �
<br />� �� 23b. DATE SIGNED (Mo„ Day, Yr.) 23c. TIME OF DEATH �'� �� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />Z November 15, 2010 08:18 PM ����
<br />� . To the bes! oi my knowtAdge. death oeeurted at the dme. date antl pla� - � 24e. On ihe baste M exaMnadan anNOr ImeadBatlon. In my opinlon death ouurted at
<br />�� and due to the cause(s) s�tetl. ( Sigreture and Title) ��� the tlme. date e�M plate and tlue ta the cause(s) stated. (Signature end TIGe)
<br />'" Kimberly A. Mickels, MD '" g s
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH7 26a. HAS OROAN OR TISSUE DONATION BEEN CONSIDERED4 28b. WA3 CONSENT GRANTED?
<br />❑ YES � NO � PROBABLY ❑ UNIaIOWN ❑ YES � NO NotAppllcable H28a Is NO ❑ YES ❑ NO
<br />27. E, TITLE AND DRE OF CERTIFlER (PHYS , HY I TAN , CORO P YSIC N A (Type or PHrrt
<br />Kimberiy A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SiGNATURE . �` 28b. DATE FlLW BY REGISTRAR (MO„ DaY. Yr.)
<br />November 15, 2010
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