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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AA�D NU�,�M,SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASI(�4'D�,PA�TMEN�' l�� HEALTH AND
<br />HUMAN SERVICES, V1TAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V��Lei�ECORD$. `�' .., � p
<br />C �' � � P
<br />DATE OF ISSUANCE j�/�� � ,^ �� - ' ` �,
<br />09/14/2012 � 012 0 9 5 4�. SFAdVLEY S. COOPER '� �•, '�:
<br />A�5'�SFAN �_ Tr E f2E ;:
<br />D�'PARTME� ��Ei4L�`�'F9 AN(�J �
<br />LINCOLN, NEBRASKA `HUNf�IGV'•SERVICES , , � ,,,•
<br />> •. ; �� , �` ..' +' ; r •"
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES�'r� ^• .�'(j F 3 Cr��`'' �• ' 1� 12 03345
<br />t�.�rci ir��H� � �r ur�+►i n °� �., ..
<br />7. ECEDENTS-NAME (First, Mlddta, Last, Suftlx) 2. SEX �; ��'.�A, E OF,DEAT.H�Mo., Day, Yr.)
<br />Janet Marie Ross Female �`� `^. Se� emFSe� 9, 2012
<br />4. CI7Y AND STATE OR TERRITORY, OR FOREION COUNTRY OF BIRTH Sa. AGE � Last Blrthday b. UNDER 1 YEAR 5e. UNDER 1 DAY 8. DATe,OF 81RTH (Mo., Day, Yr.)
<br />(Y�•) MOS. DAYS HOURS MINS. �
<br />Sidney, Nebraska 60 May 26, 1952
<br />7. OCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />507 OSH PITAL � InpaUe� OTHER ❑ Nu►sing HomeILTC � Hosplce Faclllty
<br />Sb.: FACILITY•NAME pT �rot I�tltutton, give street arM numbe� � ER/Outpatlent ❑ Decadeirt's Home
<br />�
<br />� Saint Francis Medical Center ❑ ooa ❑ otner (spectry�
<br />�
<br />8c.'CITY OR TOWN OF DEATH pnctude 21p Code) 8d. COUN7Y OF OEATH
<br />c Grand Island 68803 Hall
<br />� 9a. RESIDENCESTATE 9b. COUNTY 8c. CITY OR TOWN
<br />w Nebrask8 Hall Grand Island
<br />� 8d. STREET AND NUMBER e. APT. NO. 8f. ZIP CODE 9g. INSIDE CITY LIANTS
<br />�, 30271daho Avenue 68803 � v�s ❑ No
<br />a 10a MARITAL STATUS AT TIME OF DEATH � Marrled ❑ Never Married 10b. NAME OF SPOUSE (Firet, Middle, Last, Suffix) Ii wHe, give malden rrame
<br />� Married, but saparated ❑ Widowed ❑ Dtvoreed ❑ Unkrrown
<br />� ❑ James E Ross
<br />m
<br />� 11. FATHER'3-NAME (Flret, Middle, Last, SuHbc) 12. MOTHER'S•NAME (First, Middle, Maiden Surr�me)
<br />m Lumir Paul Studnicka Ella Schlaman
<br />�' 13. EVER IN US. ARMED FORCES? Glve datea oT service H Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />� nes, No, or unk.) No James E Ross Spouse
<br />,$ 15. METHOD QF DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 78c. DATE (Mo., Day, Yr.)
<br />� ❑ sur�ai ❑ oonaeon Not Embalmed September 10, 2012
<br />� CremaUon � ErrtombmeM 78d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (SpeeHy)
<br />Central Nebraska CremaUon Services Gibbon Nebraska
<br />178. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, Ctty or Town, State) 17b. Zip Code
<br />Apfei Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801 .
<br />CAUSE OF DEATH See Instructions and exam les
<br />1& PART L EMer the chain oT eve� �dlseasea, InJudea, or complic¢tlo�4hat dlrecUy ceu�d the death. DO NOT eNaz terminal eve�rts such ee cerdlac ertast, ; APPROXIMATE INTERVAL
<br />reapiraMry arteat, or vemricular flbAilatlon wtthout ehowing the etlotogy. DO NOT ABBREVIATE. E�rter only one eausa on e Me. Atld eddklonal Ii�ree If necesaery.
<br />IMMEDIATE CAUSE: ; oreet to death
<br />�owre cnuse � a) MetastaUc Breast Cancer E 14 Years
<br />dlsease or comlttion resulting
<br />1O �� DUE TO, OR AS A CON9EQUENCE OF: ; onset to death
<br />eequeMially Iiet conuitlone, tt b)
<br />anyr. Ieading ta the tauae IISOed
<br />on Iure a DUE TO, OR AS A CONSEQUENCE OF: � a� � d��
<br />EMe�tlreUNDERLYWOCAUSE C )
<br />(disea� or InJury that IniUated
<br />�evanes resumne In tleath) DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />d)
<br />18. PAR7 II.OTHER SIGNIFICAN7 CONDITIONS-CondlUons co�rtributing to the death but not reaulUng in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br />Ovarian Cancar OR CORONER CONTACTED?
<br />�
<br />❑ res � No
<br />W 20. IF FEMALE: 27a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21e. WAS AN AUTOPSY PERFORMED?
<br />� � Notpregna�rtwlthlnpaetyear � Natural � HoMWde � DriverlOperator � �S � NO
<br />� �Pregnarrt�ettlrt�eofdeath � � �Paesen8er
<br />Acclderrt Pendln8 �mestl9edon
<br />� Not pregnaM, but preg�mnt wkhin 42 daye ot death � Pedestrlan 21d. WERE AUTOPSY FlNDINGS AVAILABL
<br />� � swdae � Could rtot be determirted TO COMPLETE CAUSE OF DEATH?
<br />� � Not pregMan►. but pre8nant 49 days W 1 Yaar before Geath � Other (BP�b)
<br />� � unknown H pregnairt wlthin t1re paet year ❑ YES ❑ NO
<br />�' 22a. DATE O� INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, etreet, factory, oftice bulldl�, cor�structlon site, ete. (Specify)
<br />E
<br />�
<br />� 22�. INJURY pT WORK? 22a. DESCRIBE HOW INJURY OCCURRED
<br />H
<br />❑ YE$ ❑ NO
<br />22C. LOCATION OF INJURY - STREET 8� NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />' 23a: DATE OF DEATH (Mo., Day, Yr.) � 24a. DATE SIONED (Mo., Day, YrJ 24b.17ME OF DEATH
<br />E September 9, 2012 .� �
<br />�� 23b', DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH �� k r 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />$ o Se tember 10, ,2012 03:32 PM y &&& < o
<br />��dd 3d: To the haet of my Imowiedge, death oceurtad at the tlme, date and place $ q 24e. On the basie M esaminetlon enNar imastigatlon, ln my opinlon death neeurtetl at
<br />�� „entl Aue to the cause(s) etateA. (8lgnature entl Tkie) �� tlte Ume, dete end plaae end tlue to the cauae(s) afated. (SlBnature and Tkie)
<br />~ Gtary SettJe, MD ~ g s
<br />25; DID TOBqCCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YE9 � NO Not Appllcable H 28a Is NO ❑ YES ❑ NO
<br />2. E, T L D DRESS OF ERTIFIER ype or rlrrt
<br />Gary Settje, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTIRARS SIGNATURE �- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 12, 2012
<br />a►s�i �: - �
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