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1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Anna Eli,a Long 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) March 16 2010 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Lincoln, Nebraska 5a. AGE -Last Birthday (Yrs.) 91 50. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) September 10, 1918 MOS. DAYS HOURS - MINS 7. SOCIAL SECURITY NUMBER 505-26-4/62 80. FACILITY -NAME (11 not institution, give street and number) Lancaster Manor 8a. PLACE OF DEATH HORPITAI • ❑ Inpatient QIHEH: " lg Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient - ❑ Decedent's Home ❑ DOA ❑ Other (Specify) , 8c. CITY OR TOWN OF DEATH (Include Zip Coda) Lincoln 68502 8d. COUNTY OF DEATH Lancaster 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Lancaster 9c. CITY OR TOWN Lincoln 9d. STREET AND NUMBER 1001 South Street 9e. APT. NO 91. ZIP CODE 68502 9g. I INNSIDE CITY LIMITS 71 YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH 0 Married ❑ Never Married ❑ Married, but separated df Widowed ❑ Divorced ❑ Unknown 100. NAME OF SPOUSE (First, Middle, Last, Sutler) If wife, give maiden name. Lyle Long 11. FATHER'S -NAME (First, Middle, Lasl, SuttIol James B. Brown 12. MOTHER'S -NAME (First, Middle, Malden Surname) Jane B. Beekman 13. EVER IN U.S. ARMED FORCES? Give dales of service If yes. no, orunk.) No 148. INFORMANT -NAME John Frey 14b. RELATIONSHIP TO DECEDENT Attorney (Yea, 15. METHOD OF DISPOSITION ❑Burial ❑Donation bl Cremation ❑ Entombment ❑Removal CI Other (Speedy) 16a. EMBALMER - SIGNATURE Not Embalmed 16b. LICENSE N0. 16c. DATE (Mo., Day, Yr. )* March 19, 2010 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY (TOWN STATE Lincoln Cremation Service Lincoln Nebraska 17a. FUNERAL HOME NAME AND MAILING Roper and Sons, Inc., ADDRESS (Street, Chy or Town, Stale) 4300 1 0• Street, Lincoln, Nebraska 17b Zip Code 68510 CAUSE OF DEATH (See instructions and examples) 18, PART I. Enter the chain of evenli-- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, I ' APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without !Mowing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. 1 IMMEDIATE CAUSE: �► ( J[7 I onset to death (a) C � e VeArk `��C IMMEDIATE CAUSE (Find r onset to death�� CCE O " ' ` 1 1\i disease or condition resulting DUE TO, OR AS A CONSEOUENF: 1 \ ' In death) (b) jk - h Ste, I 1, , 1 "1r7 - MId1Y list conditions, DUE TO, OR AS A CONSEOUE E OF: I onset to Beat NNCC If my, leading to the cause listed on line a. I UNDERLYING 1 Enter the (c) CAUSE (disease or in(ury that DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death Initiated the warns resulting 1 In death) LAST (d) I I 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART 1. Ytl el teg,k\u, 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ),. 20. IF FEMALE: <Not pregnant within past year 0 Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of deem yyyo ❑ Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year 1 21a. MANNER OF DEATH ❑ Accident❑ Pending Ihwestlgatlon ❑ Suicide ❑ Could not be determined 21b.IF TRANSPORTATION INJURY ❑ Driver/Operelor ❑Passenger ❑ Pedestrian ❑Other (Specify) No WAS AN AUTOPSY PERFORMED? ❑YES ..r ry 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m _ 22c. PLACE OF INJURY -At hone, farm, Street, factory, office building, construction alto, etc. (Streaky) ►� 22d. INJURY AT WORK? Q YES COO 22e. DESCRIBE HOW INJURY OCCURRED 221. LOCATION OF INJURY - STREET a NUMBER, APT. NO. CITY /TOWN STATE ZIP CODE aW T� M 4 8 52 ~ 23a. DATE OF DEATH (Mo., Day. Yr.) March 16, 2010 23b. DATFISIGNIDlo.,JZeV,YS.) 23c.TIM DEATH D/ ��UU 11 00 p. m 0E 1 a J ' 24a. DATE SIGNED (Mo., Day, Yr.) 246. TIME OF DEATH m 24a PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD m 23d. To the beat of my knowledge, nth occurred at the tine. date and place causeate . Signature � and * Tme) ♦ and du the Si )1\ tit t Sgt II M 5 ° 4e. On the basis of eoaminalon and/or investigation, in my opinion death occurred at 8 g § the Sine, date and place and due to the cause(s) stated. (Signature and Title 1 • U n CONSENT GRANTED STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND' HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPAA7iMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS, 1 1 .e DATE OF ISSUANCE DEC 0 4 2012 LINCOLN, NEBRASKA 201210879 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLErS.COOPER. ` , ASSISTANT REGISTIAR OEPJAR70Elk�`T10 .I1EALTH AND HUMAN SERVICES A i' C) 10 22326 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSU DONATION BEEN CONSIOent�r 126D. WAS ❑ YES lakNO ❑ PROBABLY ❑ UNKNOWN I Q YES -'NO Not Applicable i1 28a is no ❑ YES 27, NAME R TLE AND < La .a l DD 1 SS 0E ICIAN, CERTIFIER (PHY PHYSICIAN ASSISTA , CORONER'S SI IAN OR C UNTY ATTORNEY) (Type or Prig 03 / / {.,.. .. , YAP I r» A Y1 �-�1 -r ` ih tY i _; �« )I V iv9 �D`� iej HHS-61 Rev. 7/09 (55061) 28a. REGISTR S SIGNATURE 28b. DATE F irm Giriloio.. DAY. Yr.)