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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 ¢¢
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<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 />
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