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STATE OF NEBRASKA
<br />WH6N THIS COPY CARRIES THE RAISED SEAL OP THE NEBRASKA DEPARTMENT OF HEALTH 131t1�)-l-il�IMAIy ERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE �11EBRASK74'D��AR�,M��OF HEALTH AND
<br />I HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEpOSITORY FOR 1/3�'�.`�CDR�DS
<br />� , ., � � �i, a
<br />� DATE OF ISSUANCE � � � � ��� � �� �t!��� �;;
<br />�p p 2 0 i 2 0� 19 4 ���,��� � �OOP�R �r ��. w��� .
<br />�VOV �a � Z�1� ;4:3S�fixAIUF�T'A�"E,`RE�IS,_TftXfjt`�r�-� i,
<br />�i��XM�;�OFyHEALTI°I Al�tfl r
<br />LINCOLN, NEBRASKA H��1� S� Y/rGES ' ` y
<br />- - , ; ��, �' � t 4
<br />�" 6 ��„ � x .� . , � � � �v. .
<br />$TATE OF NEBRA3KA - DEPARTMENT OF HEALTH AND FIUNIAN SER'i/�CE9" �, '�' ���'�'•_� +� C�'�
<br />CE C TE DEATH ��','" .��_ 4;� �� 6'`' ,
<br />1. DECEDENT&NAEAE (Flret, Middle. Laet 8aftk) 2 9EX .' 3. bF.D�ATFI (�o: A�y Yr.) ;: r '
<br />c, � 4 i
<br />, Josephine Emelia Cool Female '� Novem'ber 14, -2011 }'" •
<br />� 4. C1TY AND STATE OR TERRR�RY, OR FOREItiN COUNTRY OF B�tTH 8a. A�E-Last Birthday 8b, UNDER 7 YEpR Bc. UDIOER 1 CAY & Op7'E OF BIRTH (Mu.,1.1ay; Yr.) '`�
<br />(Yrs.)' M09. DAY9 HOURS MIN& , '
<br />' Mema, Nebreska 88 February 20,1925
<br />�. socw. sECURtnr NumeQt ,
<br />� �.nce oR oeaTM
<br />HOSPITAL Q �nt�em
<br />� �F Bb. FACILI7Y•NAME pf not inad '6i8on, g�ve etreet and numba� � EWOutpatlern
<br />_ ' Tiffany Square Gare Center � °0 A
<br />ec. cm oR Towni oF o�►ni �u�cu,aa z+a cata)
<br />� Grand Island 68803
<br />z
<br />9IH�; � Nmsing Honm/LTC
<br />� DeaedenPe Home
<br />❑�c��_
<br />COUNTY OF DEATN
<br />� Hoeplae Fadlily
<br />� ea. �sro�cp-ara� sa. counmr ea cmr oq rawn►
<br />, Nebraska Hall Grand Island ?
<br />� � Bd. STREET AND NUAABER 8e. APT. N0. 8/.21P CODS 9g. �NSmE CITY L1MRS
<br />�' 518 Plum Rd , 68801 � r« ❑ No
<br />� ; 70a 67ARPTAL BTATUS AT TiAAE OP DEATH ❑ Admrled ❑ Nener tllanied 10b. NNNE OF 8POU3E (Flmf, AAlddle. Laet, ''SuftOc) BwNe, giva malden rrema
<br />,, p eeamea, a+e.eaameea � ymao�vea p oroorcea ❑ ummown Glenn Dale Cool
<br />Q ' � 11. FATHER'Bd�AMH IFlrat. EAldtlle. Lest, Sufllx) + 12 EAOTHFA'&NAAU� (Rtrat, bpdt�e, EA�dan Suma�tu)
<br />O
<br />� p � PaW Herman Safranek Car
<br />m ;13. EVER M U.B. ARMED FORCE$9 C�fve detes otserrica HYes. 14a INFORIdANT-NAME
<br />H �
<br />�� 1re�, No, or unk.� o LaDonna Karleen Cool
<br />° ,18. METHpO OP GISPOSITION 18a EMBALAAERSIONATURE
<br />�� � Not Embalmed
<br />�c�u� Oe�
<br />��,,, ��� �sa. ceeeei�r, c�mnmmr oR on�ea �ocanoN
<br />CenUal Nebraska CPemation Senrices
<br />�77a FUNERAL HOMH NAMH AND MNLINO AtlDRE83 (8treel, C(ty or Town; 8tateJ
<br />��All Faiths Funeral Home, 2929 S: Locust Street, Grand Isiand, Nebraska
<br />causE a
<br />�1l. PAR7' L Ewrtps �baln oleventa. �. �+J�1ee� m eompOmtbne-that tlIn
<br />'�0�� e�aM, m'vantriculertibROation wNhout shqwing tlb aUologY. DO NO7
<br />IMMEDIA 8E:
<br />IpAA9EDtATE CAUBE (Flnal f
<br />dfsease or condltlan resut2ing a) .
<br />1� deaNl) �
<br />DUE TO, OR A$ A COP EQUENCE OF;
<br />8 Uet conditlo�re, ti , )
<br />re
<br />�+r. �m� io ma �e n�a ° {�y
<br />°h nrte a' ' DU8 T0, OR 8 A CONSEQUENCE OF:
<br />8pterthe UNDERLYMO CAUSE �1
<br />(e�saase m InJury tliat IntHatad
<br />��� �d� � d�) DUE T0, OR AS A CONSEQUENCE OF:
<br />4,►eT
<br />mre cauca on e
<br />14b. RELATtON8FOP TO DECEDENT'
<br />18b. LICEN$E NO.
<br />18c. DATE (AEo., Day, Yr.)
<br />November 18, 2011
<br />ara�
<br />Nebraska
<br />17b, ap C
<br />68801
<br />. i _..._.........�.. ......
<br />� onsa! to death
<br />� �_ ,
<br />' y �r..f
<br />�
<br />�
<br />� onset M dith
<br />�
<br />1 � '
<br />, � onset M deafh
<br />i
<br />i
<br />� onset W deafh
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<br />dI �
<br />1& PART Q. OTHER SIONIFlCANT CONDT170N&CondNlorre !o tlte death but irot resWting In the urMeriyfng ca�me gfven in PART L 18. WAS EAEDICAL EXAMINER
<br />J ORCORON6RCONTACTED?
<br />� W�� y � � � ` ❑� �o
<br />F , � �� • � �-� Tle. OF DEATH 216. IF TRANBPpRTATIqN INJURY 21a WA8 AN AUTOPBY PERFORAAED?
<br />41�� t�n�rrc a�tr� Ne p Honucta. ❑ rntrerrcae�mr p yES �o
<br />u�i [�7�� ac ame a aeau, ❑ a�taeM ❑ Pmulle9 �aed8atlon '
<br />V � P � Z,d. WEREAUTOPSI►FLYDPIOSAV,►O.ABLE
<br />QNot P���R but PreBnartt wftldn 47 days of d�th ❑ 8ukide � CoWd rrot be tletermtned ❑ Pedestrian TO CO�APLETE CAUBE OF DFATH?
<br />.'c pb��nm�s.e�c�aaa�eoar�uero�a�n, ❑o�re.tea p� �
<br />� �un�mown n preAnmrt wrem� e,e pase yea.
<br />� _
<br />o �'!a. DATE OF INJURY (Mo., Dsy, Yr.) 22b. TiME OF INJURY 22c. PIACH OF IMJURX-At home� farm. etreeR �aCtorY. bffioe M�IrIIng, eonatructlon ette, etc. (SP�KY)
<br />� m
<br />� �IId.1NJURY AT y�ORK? 22e. DE9CWBE HOW INJURY OCCURRED
<br />�- � r�,y �� No -
<br />2�f. LOCATION OF INJURY • STREET 8, NUAA9ER, APT. NO. CfryITOWN 8TATE ZIP CODE
<br />.
<br />�ia. UATE OF OEATH (ASO., Day, Yr.) 24e. DATE 8IONED (AGo., Day. Yr.) 24b. illIAE OF DFJITH
<br />� November 14 2011 ��� m
<br />236. WITE SIONID (!Ao„ pay, Yr.) 23a TpVlfi OF DEATH �> k� 24a, pF20NOUNCEb DPJID (Mo., Day, Yt.) 24d. TIAAE PRONOUNCED DEAD
<br />�, o Novem�er 15, 2011 : 1: 0 0 p- m a�, < z m
<br />�� o n� mm , a�w ��e ene m�s, aem ana Piace � u � ° zee. on aa ms�e m•xa,mnanon a�uum a�eanon. m m m,wo� a� �rrea
<br />ace
<br />p ��' ) (� 8 �� e� � O O at tl t� f i n m, date mM piaoe and due to 9re eauae(a) elated. (SlgnaWre end Tttie)
<br />~ � ~ c�i o
<br />28: DID TOBACCO U9 NTWBUTE TO THE D�ATH? 28a HAS OROAN OR 7793U� NAT10N BEEN CONB�DERED9 16b. WAS CONSENT ORANTED?
<br />' � YES Q�140 PFiOHABLY ❑ UNKNOYVN � YES [�NO NotApplieable B 28a Is NO ❑ YES �IVO
<br />T7. NAME, TITLE AND ADDRE53 OF CERTIFIER (PHYBICIAN, PHYSICU►N I�4,418TpNT. CpRpNEIY9 PHYSICUW OR COUNTY ATTORNEY� (Type o► PAnt)
<br />Ryan:��ouch D.O. 800 Alpha St.,, Grand Island, NE 68903
<br />29a. REGISTRAR'8 &IONA7UR6 f 28ti. DATE FlLED BY RECiISTRAR (Mc.. DaY� Y� )
<br />�1� 4VOV 1 ? 201�
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