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� STATE OF NEBRASfCa � ;;. , :�: ��, ' ,
<br />WHEN THIS COPYCARR/ES THf RAlSED SEAL OF THE NEBRASKA HEALTHANd IHl31UTAN SEfdV/��S '.
<br />SYSTEM, IT CERTIFIES THE BELOW TO BEA TRUE COPYOF THE ORIGINA4 RECORQ ON'F1k�:WITH ;;
<br />THE NEBRASKA HEALTH A11►D NUMAN SERVICES SYSTEM, VITAL, STATISTJJ�S�E�'T-J�H1C�! /5 ' �
<br />THB �EGAL, DEPOSITORY FOR VfTAL RECORDS - = I
<br />;� = - .� �� ' �
<br />DATE DF ISSUANCE � _ _ � "�� � ,
<br />MAY 0 � 200� Qryc �, t = - r��r�: c�i� ,'��� , , .
<br />LIN(�:OLN, NEBRASKA �G lJ� � (�+ V (7 ! V � , ', ,�y ��-A� �i�'N ;J �
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<br />, 1 .. , 1D �:::_ V ° h _ �' .'.' � j,•
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<br />3TATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICE�S FINA�tlF� - r �p
<br />CERTfFICATE OF DEATH ` -- � � �
<br />�9�3� 1. DECEDENT'8•NAM@ (Firet, Middle, Lest, 6uHfx) 2.3EX �, a 3.PATEOFqEATH �Mo.,Day,YrJ
<br />�� s,�,'� � Barbara Ann Farris �Female '_" �
<br />A ��Y 12, 2007
<br />` 4. CITY AND 9TATE OR TERRITORY, ORFOREI�N COUNTRY OF BIRTH 6a. AQE-Laet Blrthdey 5b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF 81RTH (Mo., Dey, Yr.)
<br />,; '�� � Rearney, Nebraska cYrB.� 5 8 MO3. DAYS HouAS MiNS. June 1, 1948
<br />7. SOCIAL BECURITY NUMBER Ba PU10E OF DEATH
<br />506-58-8337 HOSPITAL: �Inpatlent � ❑Nurei�HOmeILTC ❑Hoap(ceFaclliry
<br />8b. FACILITY•NAME (If not Institutlon, give atreot and numbery ❑ ER/OutpaUeM ❑ Decederrt'sHame
<br />Good Samaritan Hospital � �, ❑ rnne��sr��
<br />Bc. CITY ORTOWN OF DEATH (Include Zip Code) Bd.COUNTY OF pEATH
<br />Rearney 68847 Buffalo
<br />8a RESIDENCESWE 9b. CAUNIY 9c. CITYOATOWN
<br />Nebraska Buffalo Shelton
<br />9d.STREEfANONUb1BQi Be.APT.NO Bf.21P00DE
<br />3Q6 C. St. B7 68876
<br />t0a. MARITAL STATUS AT TIME OF DEATH `k'I Martled ❑ Never Martled 10b, NAIdE OF SPOUSE (Firet, Mlddle, Laet, Sufflu) If wife, give mefden neme.
<br />�Mamed ,butseperated ❑Widowed ❑Divorced ❑Unknown Joel Dennis Farris
<br />9g. INSIDE CITY IIMITS
<br />�'Fl YES O no
<br />11. FATHER'S-NAME (Firat. Middle, Last, Sufli� 12. MOTHER'S•NAA1E (Firet, Mlddle, Melden Sumame)
<br />Ernest R. Ohlman Alvera Stelk
<br />13. EYER IN U.S. ARMED FORCEST �hre detes of service B yes. 14e.INFORMANT NAME 14b. RELATIONSHIP TO DECEDENT
<br />�ra9,�o,o���k.� No Kristin Daniel Daughter
<br />15. METHOD OF DISPOSI'fION 18a: EMBALMER NATURE i8b. LICENSE N0. 18c. DATE (Mo., Dey, Yr. �
<br />��� ❑no�auo� �' April 16, 2007
<br />OCrematlon ❑ Entombment 18d. CEM , CREMATO R OTHER LOCATION CITY / TOWN STATE
<br />❑a�� ❑other(Speciry) Shelton Cemetery Shelton, Nebraska
<br />�77e. FUNERAL HOME NAME AND MAILINO ADDRE33 (Street, Ciry orTown, State) 176. Zip Code
<br />Apfel Funeral Home, 1123 West Second, Grand Island, NE. 68801
<br />1& PART I. Enter the ahaln ot erente-diseeses, Injuriea, or complications--thet direcUy caused the death. DO NOT enter terminei events auch ae cardiac erteet, � APPROXIMATE INTERVAL
<br />reapiratory erreat, orventrlcularffbrlltatlon wRhout ehowing the etlology: DO NOT A88REVIATE. Enter only o�re cauae on a Iine. Add addidonel Iines H necessery. �
<br />IMMmU1TECAU3E: � onsettodeath
<br />�����E� �� � �- ; �m�r►-�r'd(�
<br />� DUE Td, OR AS A CON3EQUENCE OF. I onset ic deeth
<br />Ntleath)
<br />�,�►�n ro� �'rach-�a� h�nd�aq� ; �a�lS
<br />�'�� DUETO,ORASACONSE�UENCEOF: i onaetwdeath
<br />on Wm a
<br />�`��"��`�"°� �PCu����� �n�um�nir�5 �
<br />cm�o►m��rn�r�a c�� � IU10���1'►S
<br />+�e�sr�maemn� '
<br />� DUETO,ORASACONSEQUENCEOF, i onsetrodeeth
<br />ca� �U ��l' 1� ���t'06 � fa� �
<br />18. PART II.OTHER SICiNIFICANT CON�ITION9-CondiNone oonhibudng to the death but rrot resultlng In the umiadying ceuss given in PART I. 18. WA3 EDICAL EXAMINER
<br />ORCORONERCONTACTED?
<br />❑ YES NO
<br />20.IFFEMALE: 21aM �NEROFDFATH 2/b.IFTRANSPORTATIONINJURY 21aWM4ANAUTOP3YPERFORME07
<br />�Not pregnant w(th(n peat year 1[J Naturei ❑ Homicide ❑ Driver/Operetor �
<br />❑ Pregnant at time otdeath ❑ Accident❑ Pending Inveatlgfltlon
<br />OPeseenger ❑ YES
<br />❑ Not pregnant, but prepnant within 42 days af deeth � P 21d WERE AUTOPSY FlNDINC3S AVNLABLETO
<br />❑ Shddde ❑ Could not be delertntn� ��er (SpecHy)
<br />❑ Notpregnant,butprQgnen143dayatotyeatDelore,death COMPI.ETECAUSEOFDEATFI4
<br />❑ Unk�rown If pregrrent within the peat yeat ❑ YEB NO
<br />22a DATE OF INJURY (Mo., Day, YrJ ' 22b. TIME'OF INJURY 22c. PLACB OF INJURY At homa, farm, street, fectory, offlce bullding, conetructlon eNe, etc. (SpecHy)
<br />-- - - - -- - --'_ _ _
<br />_ - - - - -' - - _ ---
<br />- -
<br />-- m - __
<br />22dfNJURYATWORKT 22e.DESCRIBEHOWINJUHYqCCURRED
<br />0 YES ❑ NO
<br />22t.LOCATIONOFINJURY-STREET&NUMBER,APLNO. CITY/fOWN SW'E ZIPCODE
<br />23e. DATE OF D TH (Mo., y Dey, Yr.)
<br />� � ��/� /
<br />a � r 23b. DAT ICi (Ma., Day, Yc)
<br />� �O � �i//b ..
<br />� 23d. To the hest o my kn edge, death a
<br />o end Gue to t ca � J atated.
<br />H
<br />26.DIDTOBACCOUSE NTRIBUTETOTHEDE/�
<br />O YE8 �NO ❑ PROBABLY ❑
<br />27.NAME,TITLEANDADDRESS ERTIFlER (I
<br />1.� /,lle�r,� i1�1,(1,
<br />�ea.AEOisra�w�ss�c3nuTUae �
<br />24a.DATESIONED (MO.,Qay,Yr.) 24b.TIMEOFDEATH
<br />��� m
<br />23c.77b1E0FDEATH � � 24a.PRONOUNCEDDEAD (MO. ,24d•11MEPRONOUNCEDDEAO
<br />1612 m �ma� m
<br />i at tha dme, date end place ���� 24e. On the besis ai exemineticn emllor invesligatlon, in my opinion dealh occurted at
<br />Tttle )♦ .� b, � the Ume, date and place and due to the cause(s) ateted. (Signature and Tltle )♦
<br />tiC
<br />$� "
<br />� 26e. HAS OROAN Ofl TI83UE DONATION BEEN CONSIOERED7 28b. WAS CONSENT �RANTED7
<br />VOW O YE3 NO Not Appliceble ii 28a is NO ❑ YES NO
<br />;IAN,CORONER'S.PHYSICIANORCO ATTORNEY111YCeorPrkrti . � __ .,
<br />�
<br />28b. DATE FILED BY REOISTRAR (Mo., Dey, Yr.)
<br />�qY � 2007
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