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(a) IMMEDIATE CAUSE (Final (a / ThlYa- C,fC A ,.•X -_ ,11,, - b.yy.• <br />disease or <br />condition resulting <br />n9 DUE T0, OR AS A CONSEQUENCE OF onset to death <br />- <br />in death) *.per w <br />Sequentially Iist conditions, If (b) <br />any, leading to the cause listed <br />on llnea. DUE TO, OR AS A CONSEQUENCE OF; I onset to death <br />Enter the UNDERLYING CAUSE <br />(disease or injury that initiated (c) <br />the events resulting In death) <br />DUE TO, OR AS A CONSEQUENCE OF: <br />LAST onset to death <br />(t6 <br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I. <br />19. WAS MEDICAL EXAMINER <br />OR CORONER CONTACTED? <br />❑ YES ® NO <br />.y, <br />a <br />20. IF FEMALE: <br />I& Not pregnant within past year <br />CI Pregnant at time of death <br />21a. MANNER OF DEATH <br />Natural ❑Homicide <br />❑ Accident❑ Pending Investigation <br />❑ Suicide ❑ Could not be determined <br />21b IFTRANSPORTATION INJURY <br />❑Driver /Operator <br />❑ Passenger <br />❑ Pedestrian <br />❑Other (Specify) <br />21c WASAN AUTOPSY PERFORMED? <br />❑YES 140 <br />10 Not pregnant, but pregnant within 42 days of death <br />10 Not pregnant, but pregnant 43 days to 1 year before death <br />❑ Unknown 4 pregnant within the past year <br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO <br />COMPLETE CAUSE OF DEATH? <br />❑ YES ❑ NO <br />22a. DATE OF INJURY (Mo., Day, Yr.) <br />22b. TIME OF INJURY <br />m <br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) <br />22d. INJURY AT WORK? <br />❑ YES` 1NO <br />� <br />22e. DESCRIBE HOW INJURY OCCURRED <br />+ _? <br />221 LOCATION OF INJURY STREET& NUMBER, APT NO CITY/TOWN SIAIE ,. ZIP CODE <br />_ <br />f$a <br />- S y <br />m <br />r ' ^ = a <br />9 Co <br />g e 2 3d . <br />gi <br />23a. DATE OF DEATH (Mo., Day, Yr.) <br />September 2, 2005 <br />a Z <br />d s ¢¢ <br />gg <br />Rt s O <br />v = <br />-..a. 4 <br />E arz <br />24a. DATE SIGNED (Mo., Day, Yr.) <br />24b.TIME OF DEATH <br />m <br />23b. D TE SIGNED Mo., Day, Yr.) <br />„ y, <br />l � j C? > <br />23c.TIME OF.DEAT <br />Q <br />/r'00 ( m <br />24o PRONOUNCED DEAD (Mo., Day, Yr.) <br />24d. TIME PRONOUNCED DEAD <br />m <br />To th best of knowledge, death occurred at the time, date and place <br />and due to the cause(s) stated, (Signature and Title) • <br />m w z O 24e. On the basis of examination and/or investigation, <br />a C p the time, date and place and due to the <br />0o <br />in my opinion death occurred at <br />cause(s) stated. (Signature and Title ) • <br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />❑ YES p NO ❑ PROBABLY ❑ UNKNOWN <br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />Ili YES u NO <br />26b. WAS CONSENT GRANTED? <br />Not Applicable if 26a Is NO ta YES ® NO <br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) <br />Aaelekee E. Badejn M _ 32 9 Pantral Ava ¢,t-it - 1n' Ve2rn NF. FiRRL7 <br />28a. REGISTRAR'S SIGNATURE <br />' <br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr,) <br />SEP 2 6 2005 I <br />STATE OF NEBRASKA <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS- <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. v A <br />DATE OF ISSUANCE ° <br />SEP 2 8 2005 <br />LINCOLN, NEBRASKA <br />1. DECEDENT'S -NAME (First, <br />Monica <br />Cedar Raids Nebraska <br />IMMEDIATE CAUSE <br />Middle, Last, <br />Rose Ostrander <br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH <br />5a. AGE -Last Birthday <br />(Yrs.) <br />61 <br />Suffix) <br />TANE.EY S. COOP <br />ASSISTANT - STATE REGISTRAR <br />HEALTH AND HUMAN SERVICES <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANQ�EAND SUPPORT <br />CERTIFICATE OF DEATH = <br />5b. UNDER 1 YEAR <br />2. SEX <br />Female <br />5c. UNDER 1 DAY <br />18. PART I. Enter the chain of events -- diseases, injuries, or complications- -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, <br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. <br />s ••5 <br />7. SOCIAL SECURITY NUMBER <br />508 -56 -6577 <br />8b. FACILITY -NAME (If not institution, give street and number) <br />Good Samaritan Hospital <br />8c. CITY OR TOWN OF DEATH (Include Zip Code) <br />Kearney 68847 <br />9a. RESIDENCE -STATE <br />Nebraska <br />9d. STREET AND NUMBER <br />1008 North Sheridan <br />9b. COUNTY <br />Hall <br />10a. MARITAL STATUS AT TIME OF DEATH LXMarried ❑ Never Married <br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown <br />11. FATHER'S -NAME (First, Middle, Last, Suffix) <br />Joseph Nicholas '' <br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. <br />(Yes, no, or unk.) N O <br />15. METHOD OF DISPOSITION <br />1 Burial ❑ Donation <br />❑ Cremation ❑ Entombment <br />❑ Removal ❑ Other (Specify) <br />16a. J= fv118ALMER -SI <br />16d. CEMETERY, CREMATORY OR 0 <br />Main Cemetery <br />8a. PLACE OF DEATH <br />HOSPITAL: Xi Inpatient <br />❑ ER/Outpatient <br />14a. INFORMANT -NAME <br />Clifford Ostrander <br />9c. CITY OR TOWN <br />Grand Island <br />8d. COUNTY OF DEATH <br />Buffalo <br />9e. APT. 140 <br />Clifford Ostrander <br />12. MOTHER'S -NAME (First, <br />Leona <br />HOURS <br />16b. LICENSE NO. <br />/©7/ <br />R LOCATION CITY / TOWN <br />Belgrade <br />MINS. <br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) <br />All Faiths Funeral Home 2929 S. Locust St. Grand .Island, NE <br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. <br />OTHER: ❑ Nursing Home /LTC ❑ Hospice Facility <br />❑ Decedent's Home - <br />O Other(Specify) <br />9f. ZIP CODE <br />68803 <br />Middle, <br />9g. INSIDE CITY LIMITS <br />lb YES ❑ NO <br />Maiden Surname) <br />''Kraus <br />14b. RELATIONSHIP TO DECEDENT <br />Husband <br />16c. DATE (Mo., Day, Yr. ) <br />Sept. 6, 2005 <br />STATE <br />Nebraska <br />17b. Zip Code <br />68801 <br />- 3.DATE OF DEATH (Mo., Day, Yr.) <br />Sept. 2, 2005 <br />6. DATE OF BIRTH (Mo., Day, Yr.) <br />June 20, 1944 <br />APPROXIMATE INTERVAL <br />