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STATE OF NEBRASICA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH •
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR J%IT.42
<br />�/ . ♦ �
<br />DATE OF ISSUANCE
<br />03/29/2011
<br />L�MAN ��RVICES, IT CERIIFIE.:
<br />!7'N�EN� Q� 1HEALTH i4ND -
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<br />D�P�4� ,MENT (jF'HP�I�Fhf AIdD � r{ :, _
<br />LINCOLN, NEBRASKA lalUMAjfaS�'i,a��CES, - �' .�<
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES ��`� £�`.'�' ta '� ��"� -` -'l� m'
<br />-"`F 11 01018
<br />�GK�irwwit�rur�►�n ,,!rr�., � _
<br />1. DECEDENTS-NAME (Plrst, Middle, Last, Sultix) 2. SIX - 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Jo ce Stewart Female March 25, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last BlRhday b. UNDER 1 YEAR Se. UNDER 1 DAY 8. DATE OF BIRTH (Mo:, Day, Yr.)
<br />(YB•I MOS. DAYS HOURS MIN3.
<br />Falmouth, Kentucky 75 July 2,1935
<br />7. SOCUU. SECURITY NUMBER Ba, pLACE OF DEATH
<br />40440-2299 HOSPITAL � Inpatle�rt OTHER ❑ Nurai� HomelL7C � Hospice Facliity
<br />8b. FACILITY•NAME (R not IrretituUOn, give atreet a� number) � ER/OutpatleM ❑ Decedent'e Home
<br />K
<br />� Saint Francis Medical Center ❑�A ❑�e� (sae�Kr)
<br />� 8e. GITY OR TOWN OF DEATH (Inciude Zlp Code) 8d. COUNTY OF DEATH
<br />c Grand Island 68803 Hall
<br />� 8a. RESIDENCESTATE 8b. COUNTY 9c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL 8d. STREET AND NUMBER 9e. APT. NO. 9I. ZIP CODE 8g. INSIDE CITY IIMITS
<br />�, 1816 N. Kruse Ave. 68803 � res ❑ No
<br />' 70a. MARITAL STATUS AT TIME OF DEATH � Married ❑ Never AAarrled 10b. NAME OF SPOUSE (Fl�at, Middle, Last, SuH6c) M wife, give malden reme
<br />�
<br />� ❑ Married, butseparated ❑ Wldowed ❑ Divorced ❑ Unknown Robert $t8W3rt
<br />0
<br />� 77. FATHER'9-NAME (Flrat, Middle, Last, Suffl�c) 12. MO7HER'S-NAME (Flrst, Middle, Malden Sumame)
<br />m John Moreland Daisy Moore
<br />�' 13. EVER IN US. ARI41�D FORCES? GNe datea of aervice H Y�. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEOENT
<br />E
<br />s (Yea, No, or unk.► No Robert Stewart Husband
<br />� 15. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 16b. UCENSE N0. 18c. DATE (Mo, Day, Yr.)
<br />F ❑ Burtal � Dontlon
<br />Not Embaimed March 28, 2011
<br />� CrertmUon 0 EMombment 18d. CEMEfERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />����� ��� Westlawn Memorial Paric Crematory Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILINO ADDRESS (Street, CKy or Town, State) 17b. 21p Code
<br />Livingston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 68803
<br />AUSE F DEATH See instructions and exam es
<br />1B. PART 4 EMer tlre chaln of eveM� 4leeasea, inJurlee, or wmpllcedonrthat tlirectly eaueed the death. DO NOT eMer terml�l everrte auch as cardiac ertesf. ; APPROXIMATE INTERVAL
<br />resplraWry arrest, or veMriwtar flbriiladan w@hout showi� the etlology. DO NOT ABBREVIATE Frrter only one muw on a Iirre. Add adtliGonallUree H neceamry. �
<br />IMMEDIATE CAUSE: ; omet to death
<br />uw�owrECnuse� 0)Interstl�alPneumonia ; Weeks
<br />diseaee or conditlon resuitlrtp �
<br />��� DUE TO, OR AS A CONSEQUENCE OF: ' onset W death
<br />3eque�rtiaily �at condidorre, lf 6)
<br />a�ry. �eaulne oo ure cauae rlsOea
<br />on Iine a DUE TO, OR AS A CONSEQUENCE OF: � orreet to death
<br />Enter the UNDERLYIN6 CAUSE ��
<br />(disease or InJury tha! InklaOed
<br />��"�"f �" �'� DUE TO, OR A3 A CONSEQUENCE OF: � onset to death
<br />� d) i
<br />18. PART 11. OTHER SIGNIFlCANT CONDITIONS�Conditlona comributlng M the death but not resulUng In the umlerlying cause given in PART I. 19. WAS MEDICAL D(AMINER
<br />Aortic Valve Replecement OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />20. IF FEM14LE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21C. WAS AN AUTOPSY PERFORMED?
<br />� � Not preB� wUhln Peat Y�r ��w� � Ho�aaa � om�non�� ❑ ves � No
<br />W Prepna�rt at tbre of deafh � PaesenBer
<br />t � � AcddeM � Pending ImesflBatlon
<br />��;, ❑� n��+. e� n�•� � a� m a�n � sw�w. ❑ co��a �a � a���a O P��^ 21d.T0 CAMPLETE CAUSE OF DEATH�
<br />� � Not p�epne�rt. but WeBnant 0.4 days l01 year 6etore death � Other (SperJfy) � YES � NO
<br />� ❑ unimam a p�e¢ns�rt.w�m the peat rear
<br />°' 22a. DATE OF INJURY (Mo, Day, Yr.) 22b. TIME OF INJURY Ytc. PLACE OF INJURY-At home, fartn, street, faetory, offlee buliding, eons6vetion eite, ete. (Spectfy)
<br />5
<br />$
<br />.� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />I�-
<br />❑ veS ❑ No
<br />22G LOCATION OF INJURY • STREET & NUMBER �.NO. CITYITOYVN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) � 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />S � March 25, 2011 � �
<br />��� 23b. DATE SIONED (Mo., Day, Yr.) 23c. TIME OF DEATH � y�� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� Z March 28, 2011 07:58 PM E�< d
<br />�� ro nre oest m my Rnow�eape. aestl, ouurrea at ure a�rre. aate ana atace g��
<br />� �� 24e. On the I�ele MeraMnatlon and/or Imeatlgatlon. ln my opWOn tleath axurted at
<br />� arM tlue to Ne seose(e) �. (SlpnaWre a�M Tttte) � the ti�. tla[e anA P��e and due to tire cause(sj etated. (Slpnature and Tkle)
<br />~ Travis S. Hageman, MD ~ g$
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED7 26b. WAS CONSENT GRANTED4
<br />� YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applleable H 28a la NO ❑ YES ❑ NO
<br />27. E, TITLE F R P SI IAN R ER P NTY A O ype or rint)
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />26a. REGISTRAR'S SIGNATURE � 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 28, 2011
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