|
STATE OF NEBRASKA � .
<br />,; .;
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND Mli�lf#N-SE�2VI��S IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITN THE NEBRASKA.�L7E�'AR�1l�F�; E7� t��F.�,4llffl
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL !d �`�� �'' "�;:i '
<br />� �
<br />DATE OF ISSUANCE /������'��' � � � �
<br />�
<br />2 0 1 2 0 4 9 5 1 5�;�,� �: � o a P�� ;,: , i� ,,,.
<br />03/01/2010 ASSI,� TXIlVT S�'�}.� RE{t;�jST�AR r�" ��'�
<br />DEI.'AR'TIJ'I�N'� Q�'H�i4E 1'f�s,!41t10 : .�a
<br />LINCOLN, NEBRASKA HiIM� �ERVIGES : �"
<br />� , � r, ,.,�
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER�IC�9 ��� L� �,'�� d �j �' {.�� ��� �'O OA46S •
<br />CERTIFICATE OF DEATH -
<br />DECEDENTS-NAME (Flrst, AAWdie, Last, Sufti�c) 2. SD( "`�� , j, :� bAT�;QF U�ATH (MO., Day, Yr.)
<br />Cleo Vergene Eads Female ; ;° Febntary 21, 2010
<br />CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last Bfrthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(NB.) MOS. DAYS HOURS MINS.
<br />Minden, Nebraska 87 March 18, 1922
<br />7. SqC1AL SECURITY NUMBER Ba. PLACE OF DEATH
<br />507-12-0162 OSH PRAL ❑ InpatleM OTHER � Nu�slrtg Home/LTC � Hosplce Facllity
<br />8b. FACILITY-NAME (If nM InstituUon, gNe street arM number) ��/p�p�neM ❑ Decede�R's Hortre
<br />�
<br />� _ Park PIac�A Colden I_ivinQ Ccanter - - ----- -- ❑ DqA _ -- - - C7 �eclsa�itr) - ---- -----
<br />� 8c. CITY OR TOWN OF DEATH (Include 21p Code) 8d. COUN7Y OF DEATH
<br />o Grand Island 68803 Hall
<br />� 88. RESIDENCESTATE 9b. COUNTY 8c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />LL 8d. STREET AND NUMBER 8e. APT. N0. 8f. ZIP CODE 9g. INSIDE CITY UMITS
<br />T 1908 Roberta Ave. 68803 � ves ❑ No
<br />� 70a. MARITAL STATUS AT TIME OF DEATH � Married ❑ Never Marrled 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) Ii wite, give malden mame
<br />� ❑ MaMea but separated ❑ v�naowaa ❑ orvo��aa ❑ u�ow„ Everettt Eads
<br />m
<br />11. FATHER'S•NAME (First, Middle, Laet, Sufflx) 12. MOTHER'S-NAME (FIr6t, Middle, Nlalden Sumame)
<br />� James Solomon Ream Maggie May Simon
<br />°' 13. EVER IN U.S. ARMED FORCES? Glve dates W servtce N Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />� �res, No, or unic.� No Everett Eads Spouse
<br />,$ 7S. METHOD OF DISPOSff10N 18a. EMBALMERSIGNATURE 78b. UCENSB NO. 18c. DATE (Mo., Day, Yr.)
<br />�,° ❑ Burial ❑ Do�mUon
<br />Not Embalmed February 23, 2010
<br />� Crert�tion � Entombment ��. CEMETERY, CREMATORY OR OTHER LOCATION CI7Y / TOWN STATE
<br />❑ Removal ❑ Other (Specify)
<br />Central Nebraska Crematlon Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street CHy or Town, State) 17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />& PART 1. EMer the chain m everne-.ui�asea, ln)urlea, or eomplicatlons4hat dlreWy ceused the death. DO NOT eirter tem�inal eve�rts wch ae rarmaa errest, ; APPROXIMATE IN'fERYAL
<br />reapiraWry erreat, or vaMrlwtaz Nbrlllatlan without ahowl� tlre etlotogy. DO NOT ABBREVIATE Emer only one cause� on a pire. Add atldidanal Mes I( ngceseary. _ i.
<br />IMME�IATE CAUSE ; onset to death
<br />memeou►re cnuse � a) Congestive Heart Failure ; Weeks
<br />dmeaee or conamon reauMng
<br />��� DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />s��am�ur i�e ��amo�, rc b) Coronary Artery Disease � Years
<br />anY� leadin9 W the eauae tleted
<br />on rore a DUE TO, OR AS A CONSEQUENCE OF: ; onset W death
<br />Fnter qre UNDERLYINO CAUSE C �
<br />(Alsease orinJurythatlniGated
<br />��"�'�d"e �" �'� DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />usT d) .
<br />18. PART II.OTHER SIGNIFlCANT CONDITIONS-CorMitiorre coriMbuting to the death but not resultlng In tha umieriying puse given In PART I. 18. W/6S MEDICAL EXAMINER
<br />Severe Aortic Stenosis, Severe MiVal Regurgttatlon, Hypertension, Hyperlipidemia oR CoRONER CON7ACTeD7
<br />� ❑ ves � No
<br />� 0. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21e. WAS AN AUTOPSY PERFORMED7
<br />F p Na P�e�eM wmm� a� r� � n�w� � rw�daa ❑ omren0
<br />� � Preena�rt et tlme of death � � � Paesenger ❑ YES � NO
<br />Acclde�rt Pentling InvestlgeGon
<br />� � Not preg�mM, but pregnaM wlthin 42 daye of death $���� ��d nat be determl�red ❑ P��an 21d. WERE AUTOPSY FlNDINGS AYAILA
<br />.o ❑ ❑ TO COMPLETE CAUSE OF DEATH?
<br />� Not Pre9�errt. but pre8nant 49 daya to 7 year befare tleatii � Other (gPec(h?
<br />� � Un�mown it pregna�rt w�th�n the past year ❑ YES ❑ NO
<br />°' ?2a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c, pLACE OF INJURY-At home, farm, street, taetory, offlce building, coretructlon site, etc. (SpecHy)
<br />E
<br />$
<br />.� 22d. INJURY AT WORK9 22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET S NUMBER, APT.NO. CITYlTOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />� � February 21, 2010
<br />� � 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF pEATH
<br />Z Februa 22, 2010 02:50 PM
<br />$� � 29d. To the beat oi my knorrletlge, tleath axurretl et the tlme, tlate antl ptace
<br />�� and dua to tha muse(s) stated. (Signatura and Tiqe)
<br />'" Jay C. Anderson, MD
<br />STATE ZIP CODE
<br />�� 24a. DATE SIGNED (Mo„ Day, Yr.) 24b. TIME QF AEATH
<br />B�
<br />�� Q� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />��o
<br />� � 24e. On the basis of examinaNOn endfor InvestlpaUOn, in my opinion death oecurted at
<br />F& $ tfre Uma. Aste an0 Place and dua to tlte causels) smted. (SIB�+ra end T(Ue)
<br />3°
<br />YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO
<br />I�, TITI / D AD RESS�I�ER P YSIC , f�C�f§7dN ('Z.O�RONER § P�I� Y:
<br />� C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />GISTRAR'S S16NATIIRE� � �.�� - r � . � . _ � . �:.. ._ . . ..
<br />fl 28a Is NO fl YES LI NO
<br />28b. DATE FlLED BY REGISTRAR (MO„ Day,
<br />February 23, 2010
<br />
|