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STATE OF NEBRASKA
<br />IEALT-�AN� �U�1,�IN1 ��R1/�ICES, IT CERTIPIES
<br />RE.�KA���iPJAII�T'�l�'�IT, , ` E��IEAlTH .4ND
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<br />�t'�'`(MENT OF,HE,�LTH iQl{�D' ✓
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORI
<br />DATE OF ISSUANCE '
<br />�1U� O 1 201Q
<br />201205125
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<br />LTIVCOLN, NEBRASKA rrulW�1FS�VIGES , . � � ,,,, .
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<br />STATE QF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVI(ICES��j`� °� ���Q� �
<br />C TF DE T � � � �-
<br />1. DECEDENT3-NAAAE (F7rst. d4dfll& �-e8t. Sufl�t) 2 SEX 'S: DATR G� DEAT iVEao.,DdYrY� I
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<br />Barbara Jean Taylor Fe�ale May 23, 2010
<br />4, CITY AND STATH OR TERRITORY, OR PORqON COUNTRY OF BIRTH 6a AOELeat Blrthday bb. UNDER 1 YEAR Bc. UNDEti 1 DAY & DATE OF BQtTH (Mo., Day, Yr.)
<br />(Y�s.l mo9. DAYB HOU� 9SA�IS.
<br />; Grdnd Island, Nebreska 69 August 12,1940
<br />7. 90CIAL SE¢URITY NUeABER Ba PLACE OF DEATH
<br />� SO H�PJ79�: ❑�P�eM 9Ii1EB:� Nuraing Home/LTC [J HoePke FadRty
<br />�' '� Sb. PACWTY=NAME (IP imt t�retikotlon. 9he street m�d nwnber) ❑ ERlOut}roedeM ❑ OecadeM e Fl�me
<br />� ' Wedgewond Care Center ❑ ooa ❑ �rtsa�nl
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<br />-� � 8c. �I7Y OR 70YYN OF DEATH (Include Zlp Code) Bd. COUN'I'Y OF DEATH �
<br />� ,' Grand Island 68803 Hall
<br />� � 9e. RESmENF�E-STATE 9b. COUNTY 9e. CITY OR TOWN '
<br />� � ' Nebraska" � �� � � Nall '�' �� � � ` � Grand Island� � �
<br />a ', 8d. $TREET AND NOAABER , M. AP'f. NO. 9E ZIP CODE 8g. IN31DE CITY LfM1T$
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<br />�,� 556 E.1�th Street 68801 � v� ❑�
<br />� � 10a, dIARITAL STATU6 AT TIME OF tlEATH � Nlertled ❑ Never 6lerried 10b. NAM6 OR SPOt18E (Flrat, NIIdrIIe. Last, Suf�) C vaNe, gtre malden treme.
<br />,❑ eaar��a; t�,e eaperama p inna�a p orwr�ea ❑ un��.n Robert Taylor �
<br />�' 1'1. FATHER'SNAAAE (f7ret, AI6drDe, Lesf. Saltlx) 12 fdOTHEIt'&NAAAE (FIBt, NUddle, , AEalden 8umame)
<br />�
<br />� irvtrn S Brawn Ema Marie Luebbe
<br />a� 1a. EVER w u.s. aRmEO FORCEB'► awa aates a servtca (f Yea t4e. wFDRdIANr-NAdse 1ab. RELanoWS►t� To nECEOENT
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<br />° (Ye�, No, or Unk) Np Pam Billin on Daughter
<br />1& METHOD OF DISPOS►iION 18a. EMBALOEER-SIGNATURE 78b. LICENSE N0. 18c. DATE (mo, Day, Yr.)
<br />���"°' ��"�' Not Embalmed May 25, 2010
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<br />�� ❑��� 18d. CEMEiERY, CREMATORYOR OTHER LOCATION CITYITOWN �BTATE
<br />Westiawn Memorial Park Cemetery C3rend IslarM Nebraska
<br />� 17a FUNERAL HOME NAME AND MA�I.W6 ADCRE88 (Sbaet, Qty or Town, State) ., � 176. �p Code
<br />', Livingston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 68803
<br />CAUSE OF DEATH (See instructions and euamples
<br />' 1&PARiLE�trtM crtal»Mwerr�-E�..h+hu�es.m.eomP��m-t�at.A�eetlYn�mENSAmIWODNOTmtnfmmlvWm�wcAaewdlaeer� . - ; APPROXId1ATE1NTERVAk. _-
<br />� resP��eto'Ymre%t,mvenbiculerNUalffiIonarA6outa�OthaeHOlogy.DONOTABBAENATEEOIeronlyam�eaonaWm.AAdadNHOnaIMesBmoea�ry.
<br />IdIMED1ATE CAUSE ' o/lset SO deefh
<br />�I6SmImtATE CAUSE (Flnal
<br />�, �; '�"'���e"� e' � '� Y �/��c u�. E � Ss�/� .l
<br />DUE TO.OR AB A CONSEQUENCE OF. ', : e�met to dea� � -
<br />�e"em� ��b► C N�N�c. oss��c.w cTr�t �,zwc� /J,sfirs�' ` �u '��
<br />°O � a DUE TO, OR AS A CONSE4UENCE dF: ; onset to deafh
<br />•� Enter tlm UNDERLYING CAUSE �) .
<br />(rRsease or Injury that Wdated DUE TO.OR AS A CONSEQUENCE OF: ; o�met Lo death
<br />the evertl8lB8Witn9 kl deatlp
<br />LJ18T
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<br />�& PART II.OTHER SIGNIFICANT CONDITIONSConditlo�m, eoMiibuting to the deeth 6ut rtot reeuitin9ln the u�der1Y1n8 cause glven In PART 4 8. WA9 tlAEDICAL DNMINER
<br />. ' 1�.1�,,1�'1'�'` 1 L`'.S� I�TILI � . �r/�I�r_ � C.��� �.� .ORCORONERCOMI'ACim4
<br />� , ❑ YES �NO
<br />W Z0. IF FEIOAI.E: ' �tte. iIAANNER pF DEf1TH 276. IF TRANSPORTATtON INJURY , 21a WAS AN AUTOPSY PERFOR6�ED?
<br />� �c n�,.w,u, a�e s�. ' �u�i 0 Ha�u�ea ❑ n��.�o��o. x' � res No
<br />❑�re�aM � m� � a� p n�aa�e ❑ r� im�nsano� ❑ r��re�r
<br />U � O Not P�eB+�eirt. but Pregnerrt wifhin 42 deYS M daath ❑ BWaide ❑ CoWd not be delemdned ❑ PedesMen 21d WERE AUTOPSY FlNDINOS AVAO.ABI.E
<br />:O '� Q Not prapnept�6ut preg�an! 43 deps to 1 Yeer betord death ❑ Othar (8peatfy3 . x a� PLETE CAU38 OF DEATH9
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<br />: E �� 2?a. DATE 061N.IURY (Mo., DaY�'Yr.) ?.�. TME OF OJJURY 22a PLACE OF WJURY-At ho�lre: farm, 6treal, taoMry. oftice buiW�. eotmtruatlon eke. eta. (BP��Y)
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<br />_ � .'. �� 22d. WJURY.AT WORK9 22e. DES4�[iI6E NONtINJURY OCCURRED �. - s' - - -_ ._ � -- - _�_ : .-. -
<br />*` ❑ ves ❑ No
<br />' T21: LOCqT10N OFiNJURY -STREET 8 NUMBER, APT. NO. CITY/TOWN � STATE Z!P CODE
<br />23a. DA7E OF DEATH (dAo., Day, Yr.) 24a. OATE SItiNED (AAo., Oay, Yr.) 24b. TIALE OF DEATH
<br />;�� Ma 23 2Q1.0 .'�'��z�, m
<br />�"' .1]ATE SI�NED (EAo., Day, Yr.) 23c. TIEAE OF DEATH �> O 24c. PRONOUNCED OFAD (AAo, Oay, Yr.) 24d. TONE PRONOUNCED DFAD
<br />N Z
<br />8�� S 1•25 m E m
<br />m � to nre uese m�r a�ow�eaee, aeam oce�ured ee um ama aem ena �ee 8�7 � zae. on me easts or �mmnanm m�aier mvesn�on, m my �►on a�m oceu�rea
<br />�� m�d due cause(s) mM Title) ,� Z� at the time, date end place mM due to tlle cause�e) s�d. (8ignaWre mM TRfe)
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<br />. DID TOBAfxQ UBE CONTRI9UTE TO THE �EATH7 HAS OROAN OR 71S9U DOItlATION 9EEN CONSIDERED9 � WAS CON9ENT ORANTED?
<br />�res Q NC ❑ PROBABLY ❑ UMINOWN �❑ res � ewe npane� a� � No ❑ res eo
<br />7! NAME. TITI.E AND ADDRE3� F CER7'ff1ER (PHYSICIAN� HYSICUIN ANT. COHONER'8 PHY9ICUW OR COUN7YATTORNEY) RYPe o► P�t)� .
<br />x� o�+✓r � z.� �rv .�n .�. �� N4� tusr�-c 6��� ,s �t�vr�_� y�' G���
<br />z9e. REGt97HAR'8 StGNn711rtE 26b. DA7E Fu-EO BY REGISiRAR ledo., Der. Yr.)
<br />P . ,(� A�AY 2 7 2010
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