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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH.AIVD�I SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR •V17'AL;RF�RDS; ',
<br />'' .� r a �! ''
<br />DATE OF ISSUANCE � �' �'��- "W- -'� ,
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<br />ST¢!iV(.EY � C�OPEft °' ' `
<br />09/11/2012 �' '" `'
<br />� 012 0� 15 5 DE�RTM�IV7`�FH�AL�H A�p •,
<br />LINCOLN, NEBRASKA HU.M�N:S�RVICES � , . ;'� '
<br />�
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC��-� �' ��� j�� f�, i '*� � � � OO4GO
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<br />1. DECEDENTS-NAME (First, Mlddle, Last, SuffGc) 2. SIX ^,., �'S: DATE OF DEATH (Mo., Day, Yr.)
<br />Terrance Lawrence Rose Male February 11, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y�•I MOS. DAYS HOUR3 MINS.
<br />Omaha, Nebraska 58 June 6, 1952
<br />7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />506-70-7238 OSH PITAL ❑ InpatlerR OTHER ❑ Nursing HomaILTC ❑ Hosplce Facllity
<br />8b. FACILIIY•NAME pf not Institution, gtve street ami number) � ER/Outpatlent � DecedenPa Home
<br />�
<br />� 2526 Stagecoach Rd. ❑ ooA ❑ o�ner (Speary)
<br />� Bc. CI1Y OR TOWN OF DEATH (6rclude Zlp Code) 8d. COUNTY OF DEATH
<br />o Grand Island 68801 Hall
<br />� ea. RESIDENCESTATE 8b. COUNTY 9c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />� 8d. STREET AND NUMBER . APT. NO. 9L ZIP CODE 9g. INSIDE CITY LINOTS
<br />� 2526 Stagecoach Rd. 68801 � res ❑ No
<br />y 10a. AAARRAL 9TATU3 AT TIME OF DEATH � Married ❑ Never Marrled 1ob. NAME OF SPOUSE (FUst, Mlddle, Last, Suffix) H wHe, gwe malden rmme
<br />� ❑ Mamea but separated ❑ �nndowea ❑ onrorcea ❑ Unknown �udy Darlene Rose
<br />� 11. FATHER'S-NAME (First, Middle, Last, SufBx) 12. MOTHER'S�NAME (Flrst, Middle, Malden Surrmme)
<br />� John Lawrence Rose Mary Frances Henry
<br />Q ' 13. EVER IN U.S. ARMED FORCES? GNe dates oi service H Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />$ �ree, No, or unk.) No Judy Darlene Rose Wife
<br />,$ 1S. METHOD OF DISPOSITION 18a. EMBALMERSIONATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F � Burlai ❑ Donadon
<br />Laurie D. Sheffield 1397 February 16, 2011
<br />❑ Cremation 0 Errtombment 18d. CEMETERY, CREMATORY OR OTHER LOCATION CIT1f I TOWN STATE
<br />❑ Removal ❑ Other (Specify)
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Cily or Town, Smte) 17b. Zlp Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See Instructions and exam les
<br />1& PART I. EMer Ne thain a(evem�-0iseasee, In)urlea, or compllcaUO�-that dlreNy pused the death. DO NOT eMer terminal eveMa such ae cartiiac artast, . ; qPpROXIMATE INTERVAL
<br />respiretory arrest, or reirtrleWar tibrillaUon withou[ showing the edotogy. DO NOT ABBREYIATE EMaz onty one ceuse on a Ilrte. Adtl edditlonal Wres H ne�ry.
<br />IMMEDIATE CAUSE: ; onaet to death
<br />IAAAIEDIATE CAUSE (Final a) Heart Failure � Immedlate
<br />dlaease or condidon reautting �
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />Seque�rtialiy Iiat conAitlone, fT b) Pneumonia � 1 Day
<br />a�ry. Ieadin8 to the cauae Ilated
<br />oe nna a DUE TO, OR AS A CONSEQUENCE OF: 0 or�et to death
<br />EMer the UNDERLYINO CAUSE C � '
<br />(dlsease or InJury that InWated
<br />the eveMe resuldng In death� DUE TO, OR AS A CONSEQUENCE OF: � orreet to death
<br />uaT d � �
<br />18. PART IL OTHER SIONIFICANT CONDITIONS�CondlUona co�rtributing to the death but rrot resulUng In the underiying cause g(ven In PART 1. 19. WA9 MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />� � YES ❑ NO
<br />� 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />F � Not prepnaM wlthin pae! year � n�a,�i � xo��aa ❑ ofire7oc0�eo�
<br />❑ ❑ YES � NO
<br />� � Pregna�rt at tlme M death � Accldent � Pending InvesGgatlon P ��
<br />a Q Not pregnaM, but pregneM wlthin 42 days of death gwWUe Could not be datemu�ree ���" z1d. WERE AUTOPSY FINDINGS AVAILABLE
<br />� Not pregnaM, but pregnaM a9 daye to 1 year betore death � � � p�ry� (gpe�y� TO COMPLETE CAUSE OF DEJ►TH?
<br />� � unimovm 1t Preena�rt withln she paet year ❑ YES ❑ NO
<br />°' 22a. DATE OF INJURY (M1�o„ Day, Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURY•At home, farm, atreet, facfory, oftice bullding, coretructlon site, ete. (Spaetiy)
<br />E
<br />�
<br />E 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />�' ❑ YES ❑ NO
<br />22f. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />B ��� February 14, 2011 Approx. 12:OU PM
<br />��� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH �� k 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� Z y < o Februa 11, 2011 06:40 PM
<br />� � � 9d. To the bea! of my knowledge, death occurted at the tlme, date and piaee $ � 24e, On the basle ot e�mminatlon end/or Imestl8adon, In rtry opinlon death oeeurted et
<br />F � aml due ta Ure ceusele) etated. (Signature arM Tltle) ���$ Ure tlme. da0e artd place artd due to tha eaueelsl afated. (Slgnature and TIUe)
<br />� �� Robert Cashoili, Hall Deputy County Attomey
<br />2S. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED7 28b. WAS CONSENT GRANTED?
<br />� YES � NO ❑ PROBABLY ❑ UNKNOWN � YES � NO Not Applieable H 28a le NO ❑ YES ❑ NO
<br />2. 71T ADD OF C TI IE ype o� PriM
<br />Robert Cashoili, Hall Deputy County Attomey, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />28a. REGISTRAR'S SIGNATURE �- � 26b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />February 15, 2011
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