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CERTIFICATION OF VITAL RECORD
<br />BIRTH
<br />NUMBER
<br />STATE OF IOWA
<br />STATE OF IOWA
<br />IOWA DEPARTMENT OF PUBLIC HEALTH
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT'S FIRST MIDDLE LAST SUFFIX, d any
<br />FULL NAME Joseph Ronald Beran
<br />2. SEX 34. AGE - LAST BIRTHDAY 3b. UNDER 1 YEAR 30. UNDER 1 DAY 4. DATE OF BIRTH (Month, Day, Year) 5. COUNTY OF DEATH
<br />Male 62 Years Months Days Hours Minutes April 26, 1950 Fremont
<br />6. PLACE OF BIRTH (City & State, or Foreign Country) 7. SOCIAL SECURITY NUMBER 8. CITIZEN OF WHAT COUNTRY? 9, EVER IN U.S,
<br />Omaha, Nebraska 507 -70 -0832 United States ARMED FORCES?
<br />❑ Yes IN No
<br />105. MARITAL STATUS AT TIME OF DEATH 10b. DECEDEMS LAST NAME PRIOR TO ANY 11. SURVIVING SPOUSE (Full name prior to any mardage)
<br />I Monied DManied but separated 0 Widowed MARRIAGE (Hever manied)
<br />I Divorced FJ Never Monied 055known _ Baran Barbara LoAnn Bredensteiner
<br />124. RESIDENCE-STATE 129. RESIDENCE-COUNTY 12o. RESIDENCE -CITY OR TOWN 124. RESIDENCE-STREET NUMBER, ZIP CODE 120. INSIDE
<br />Iowa I Fremont ` Northboro I 4007 310th Street 1 CITY o rs?
<br />l ❑ ves D No
<br />13. FATHER'S FIRST MIDDLE LAST 14. MOTHER'S FIRST MIDDLE LAST
<br />NAME NAME PRIOR
<br />Joseph Francis Baran TO ANY MARRIAGE Lucille Marion Fortin
<br />154. INFORMANTS 15b. INFORMANT'S MAILING ADDRESS (Street 8 Number, Coy, 55010, 7'p Code) 150. RELATIONSHIP j0 DECEDENT
<br />NAME Barbara LoAnn Baran 4007 310th St. Worthboro, Iowa 51647 , Wife
<br />\ 16. PLACE OF DEATH (Check only one)
<br />IF DEATH OCCURRED IN A HOSPITAL I IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL
<br />O Inp46ent Pfl 1[,]10
<br />ER/Outpatient 1594 on Arrival I ' Hdsplce Facility fNUrsing Home /Long -Term Care Facility Decedent's Home 1j Other (Specify)
<br />170. FACILITY NAME (If not institution, give 51,851 and number) 17b. CITY, TOWN, OR LOCATION & ZIP CODE OF DEATH 170, INSIDE CITY LIMITS?
<br />George C. Grape Memorial Hospital I Hamburg, Iowa 51640 ID vas 0 No
<br />DISPOSITION
<br />18. METHOD OF DISPOSITION 19. PLACE OF DISPOSITION (Name of Cemetery. Crematory, or 0125, place)
<br />❑Burial ® Cremation ❑Denetion ❑Entombment ❑ Removal from State Ho - Kilnoski Funeral Home & Crematory
<br />20. LOCATION OF DISPOSITION (City Or Town & State) 21. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY
<br />Council Bluffs, IA I Kirsch Funeral Chapel 405 W. Thomas Ave. Shenandoah, Iowa 51640
<br />220. FUNERAL DIRECTOR - Pnnletl Name 22b. FUNERAL DIRECTO '50550,0 23. LICENSE NUMBER
<br />Michael D. Kirsch . - �� I 2854
<br />PRONOUNCE NT, CERTIFICATION AND CAUSE OF DEATH
<br />ITEMS 24 -28 REQUIRED TO BE COMPLETED BY 24. DATE PRONOUNCED DEAD (Month, Day, Year) (Spell out month) 25, TIME PRONOUNCED DEAD
<br />PERSON WHO PRONOUNCES OR CERTIFIES DEATH p�p.� -�- p n
<br />G� G Ir�� / r:- � � ©,LZ "I TIME / i .1� OAM ❑PM.Military
<br />26. NAME OF PERSON PRONOUNCING DEATH (0 different than certifier) (Type or print legibly) V. TITLE 28. LICENSE NUMBER 310. MEDICAL EXAMINER
<br />a,�
<br />(MD, DO, PA, ARNP, RN, LPN) ` A �` Cc w A ..]„ D 3 ./JAy) CONTACTED? ❑ Yes /y to
<br />29. ACTUAL OR PRESUMED AT OF DEATH � -/T ' /
<br />30. ACTUAL OR PRESUMED TIME OF DEATH 31b. If Yes. ME, case number
<br />(Month, Day, Year) (Spell out month) ,,, (� ^, � 4 / ®, 0 1.0 t, TIME iF �` ❑ AM ❑ PM 1�Mllitary
<br />CAUSE OF DEATH (See instructions and examples) 329. Approximate
<br />32a. PART L Enter the chain of events - diseases, injuries, or complications - that directly caused the de Ih. 00 NOT enter terminal events such as cardiac attest, interval between onset
<br />respiratory arrest, or ventricular fibrillation without showing 5be etiology. DO NOT ABBREVIATE. Enter only one cause On 0855. Add additional Imes 11 necessary. and death
<br />IMMEDIATE CAUSE (Final disease or
<br />B. L i /Uye R
<br />4 . b7Jiq,L L /,) 4I`r � B j
<br />,R [ �
<br />condition resulting in death) Due to (or as a consequence of): a
<br />Sequentially list conditions, 0 any, leading to b ' 1 ' i b / vC7..
<br />11115 cause listed on Inc a. Enter the Due loins esaconsequence of): UNDERLYING UNDERLYING CAUSE (disease or injury 1005 5.
<br />Initialed the events resulting in death) LAST Due 0 (or as a consequence 9p:
<br />d.
<br />Due to (or as a consequence 00:
<br />320, PART II. Enter other significant conditions contributing to des h but not resulting in Me underlying 04015 51'50 In PART I. 33. WAS AN AUTOPSY PERFORMED? 0 Yes No
<br />�� J G��c 1 ' /It - ,aY IIR ✓Z7 � 1-4-7 r IV t I) f 34. Ir Yes, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />�/y p�: (a- 1 ,9(, K h'e1us.i , miYti. / Ys�s ClEQS� - I 7 5 r S n COMPLETE CAUSE OF DEATH? 0 Yes 0 No
<br />35. DISTOBACCO 050 35. IF FEMALE' i 7 MANNER OF DEATH
<br />CONTRIBUTE �! a 7�0 DEATH? 0 Not r r��L'- o 'fsnJCS $3
<br />❑ Ves to Probably pregnant within past year ❑ Not pregnant, but pregna ithin 42 days of tlea "(Natural ❑ Homicide
<br />Pregnant at time of death 0 Not pregnant, but pregnant 43 days to 1 year before death 0 Accident 0 Pending Investigation
<br />❑ No 0 Unknown 0 Unknown 'A pregnant within the past year 0 Suicide 0 Could not be Determined
<br />38. DATE OF INJURY (Month, Day, year) (Spell out month) 39. TIME OF INJURY 0 AM 0 PM 140. PLACE OF INJURY (e.g., home, farm, street, roadway, etc.) 141. INJURY AT WORK?
<br />TIME 0 Military 0 Yes 0 No
<br />42. LOCATION OF INJURY: (Complete physical address - Street & Number, Apt. O, 0105 0r Town, Stale, Zip Code) 43. IF TRANSPORTATION 0131.107, SPECIFY:
<br />0 Driver/Operator 0 Passenger 0 Pedestrian
<br />ID Other (Specify)
<br />44. DESCRIBE HOW INJURY OCCURRED:
<br />45. CERTIFIER Certifying Mx - D, : V P -To the best of my knowledge, death occurred at the time, data, and place, end due to the cause(s) and manner slated.
<br />(Check only onSl» r 1 � ) - On the basis of examination an4/01 investigation, in my opinion, death occurred at the lime, dale & place, and du to 000 cause(s) 6 manner stated.
<br />Signature Allr . 11' 46. TITLE // 41. DATE CERTIFIED (Month, �`fJ ' f-
<br />Day, Year) - 1 1
<br />48. NAME 8 COM' ETE AILING ADDRESS OE CERTIFYING PHYSICIAN OR MEDICAL EXAMINER 49. LICENSE NUMBER
<br />Me/ i� 42flM MD, 1279 a�.r >,i NA�r& r r4 � ' O 3Rt)
<br />5 2 /It REGISTRAR ONLY - REGISTRAR SIGNATURE 500. DATE RECEIVED BY REGISTRAR (Month, Day, Year)
<br />PYI kFh'��(I P Pln� et 7 Book 7 Pake 223 September 24. 2012
<br />This is to certify that this is a true and correct reproduction of the original record as recorded
<br />in this office, issued under authority of Chapter 144, Code of Iowa.
<br />This copy not valid unless prepared on engraved border displaying state seal and signature of the Registrar.
<br />FORM #588- 0328C(03/2010) WARNING: IT IS ILLEGAL TO DUPLICATE THIS COPY
<br />COUNTY
<br />ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE T
<br />? d# "t`' ..G>l,Y n,V ry'tr
<br />ig 0520
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