|
W
<br />O
<br />d
<br />16
<br />I St.
<br />I, `
<br />TARO I Tr !UM 3 G..Y[ aJaT a n
<br />1 .D Blrs4uWE (not, MOB, Lad, MM
<br />Catherine Kay Cremeen
<br />TLW
<br />Female
<br />e3. DATE Of Norm mw,Oa,Y.)
<br />January 11, 2014
<br />1. CITY AND STATE ORTYORY, OR FOWAON OOSRIThY OF T H
<br />St. Paul, Nebraska
<br />IL AGE-Last ibNdq
<br />(TIS,)
<br />59 ;
<br />lb. UNDER IYEAR
<br />M. MOM 1DAY
<br />S. DATE OF MOH 112., Day, Yr)
<br />August 8, 1954
<br />MOS.
<br />DAYS ';
<br />HOURS
<br />IOW.
<br />7. SOCIAL'. SECURITY NUMBER
<br />507 -74 -5027
<br />_ M. PLACE OF DEATH
<br />UQINSTAJ O QmaRk❑ Pluming MO,tiILTC ❑ Hospice FaalMy
<br />❑ ERrou+adlad ® O+oadant'o Ham
<br />❑ 00A porla(SpoaRP)
<br />ML FACSJTY4LAIR (N not bwlNdbn, d..alabed and numbed
<br />2303 N. Huston
<br />S CITY OR TOWN OF DEATH ( MwM Bp Cods
<br />Grand Island 68803
<br />M. COUNTY OF DEATH
<br />Hall
<br />RESIDENCE-STATE
<br />Nebraska
<br />!b. COUNTY
<br />Hag
<br />TOWN . CRY OR TOM
<br />Grand Island
<br />M. STREET AND NUMBER
<br />2303 N. Huston
<br />N. APT. NO.
<br />x a COOE
<br />68803
<br />SS• NNOE CITY WAITS
<br />E Y« ❑ Na
<br />14a. MARITAL STATUS AT TIME OF DEATH la Mobil ❑ Ilan"
<br />0 uar,i.t Ind aapralad ❑ waa..d ❑ Mamma ❑ ada».n
<br />low MANS! OF SPOUSE IRaL Middle' Lrl, aoMq S aSe, t1�a "din tines
<br />I D g la s W Cre meen
<br />tl'P
<br />11. FAT11BCtNAME (FIFA ... MI4tSS. LIM, SIM)
<br />John Kramer
<br />IL NOT)ECS.NAME (Fiat. Wide, NYdan &MI I
<br />` Neva Whadtman
<br />19 .EVHtiU.I..MIiD FORCES? 0M dim al mimics NYaa
<br />(w ND, or Un No
<br />14a. INFORMANT-NAME
<br />Douglas W Cremeen
<br />1l. NEI17gMS1/TODE ENT
<br />Spouse
<br />IA METHOD OFOMFOI M ON
<br />O .." ❑D°" .."
<br />111a. BB ILMi - UIONATURE :
<br />Not Embalmed
<br />1111s. UCEME NO.
<br />IS.. DATE (Mo., Day, W.)
<br />January 11, 2014
<br />" F,a...a...
<br />o - , DoU- ...M
<br />11111. CEMETERY, CREMATORY OR O111ER LOCATION GTYROYM/ STATE
<br />Central Nebraska Cremation Senior* Gslbo Nebraska
<br />171. FUNERAL NOME NAME AND MAILING ADDRESS MOW, CSy or Toms, Melo)
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />170. Op Cod.
<br />68801
<br />'
<br />To Be Comp stM by: CERTIFIER
<br />CAUSE OF DEATH (See Instructions and examples)
<br />14 PART I. !Wm si itM -at.. ... Mrb& llsMa menta says .•dran&DO MT..aar1...Y." earns w.a moles .rat. :: APPROXIMATE M10 JAL
<br />A ,..A. or vwOkWaa"Y.Waal drafts BsWeleN. SO MDT ANWM1E. law mews Wow eaa So. Add :WWWWam Y..a.wy.
<br />WNEOMTE CAUSE :: anad to daaa.
<br />ElNEDIATE CAUSE (Filet
<br />dbaaaaar " w -Q m (vpm all d '[o s v„,,0., v,
<br />DUE TO, OR : awdSo death
<br />StVrwdbN, Nat aa«ldo,M K by
<br />any, Ybdl.q p the owes 1loltd /a
<br />an Um I. DUE TO, OR AS A CONSEQUENCE OF. mono loth
<br />Eater Ma UNDERLYING CAUSE
<br />thom aoarrny that O O D TO.OR ASA CONSEOUENCEOP: and to dedi
<br />tl,a a.ada �anl M daaal
<br />LAST
<br />Y: FART IL OTHER SIOIWNCMR CON01110111343oneSona ooNnbutMe bllsdid but sotrrdl,.S In Me rnda,MnS:orra Own* PART L
<br />24,111
<br />OR AS WI t Al.O TAC7l6T
<br />❑YES is ND
<br />F FEMALE:
<br />Not prugnsotwithin pad yes
<br />❑ P ogn.it at Mao ordeals
<br />❑Ndp,monad. but pregnant MEM 42 dtra of der,
<br />OHM pn S•a d. Gut pra0 .r4143 days l.1 year Oaten d emi
<br />❑Urbnovw N pregnant ?MOM nt post yaw
<br />06. MANIER OF DEATH
<br />I3wr ni ❑ Hoeddi`
<br />❑ Aaoldad ❑ Pandas YwoMlpdon.
<br />, ❑ S,dolde ❑ card not bodd.abssd
<br />215. F TRANpCRTATE INJURY
<br />❑ od.alononnor
<br />❑ PaaarMPr
<br />Q.P.d..blti
<br />;� ❑ Mar (Spay)
<br />21a. WAS AN AUTOPSY PERFORMED?
<br />❑ am gg NO
<br />214 WERE AUTOPSY FINDINGS AVAEABLE
<br />TO COMPLETE CAINE OF DEATHT
<br />AYES 0 NO
<br />794 DATE OF INJURY (No., Oa, W.) :.
<br />rib. TWA OF INJURY .
<br />M
<br />Maas oa isusdun Ma, MA (R.dly)
<br />Os. PLACE OF SLRNIY It Mao,laal, moot, Pam °Moo
<br />214 INJURY ATWORK?
<br />❑ YES ❑no
<br />Etc ammo NOWINJURY OCCURRED
<br />- .
<br />27r LOCATION OF *AIRY- STREET & NIMM I% APT. NO. CRYr1OWN STATE ZR CODE
<br />Oa. DATE OF DEATH (Ms, Day, Yr.)
<br />January 11, 2014
<br />-
<br />kii
<br />Zia. DATE WINED (1114, Gay, Tr.)
<br />24b. OM OF DEATH
<br />m
<br />E
<br />990. DATE SIGNED (Mo., Da Vt.).
<br />January 11, 2014
<br />ry
<br />23o. TEE OF DEATH
<br />6:10 A m
<br />MAs. PRONOUNCED DEAD (No., Day, Yr.)
<br />,
<br />tad. TIME PRONOUNCED DEAD
<br />m
<br />• 7 . ToWa bast ofm ylo,oModge,RAM mama! atWs Om, dB* Ntlplw
<br />' \ and duo bSrowes(s) ar (MFyrro and TEM)
<br />7 (I -
<br />744. On So be* e WirlmadgdbRAI sWAPS1101 dos* ooaynd ...
<br />Cl the line, ode .1d puss msd due tEacSNN5)*MA Gillimbm 0 mew
<br />SOD TOBACCO USE CONTRIBUTE TO 711E 0EA1110
<br />YEs ❑ ND ❑ PROSMLY ❑ maxim
<br />OR TISSUE DONATION SE M CONSIDER D7
<br />❑ YES IP NO
<br />I. WAS camera Gammo n
<br />Nol w er:a6 N N 91. Y NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADORERS OF CERTIFIER (Typo or PAM)
<br />Melham Jabbour M.D., 2116 W. Faildey Av., P0 Box 9804, Grand Island, NE 68802 -9804
<br />P
<br />9Pa. RiMSTRAR'a SIGNATURE
<br />ArAi J. 60Pi/
<br />1110. DATE FILED BY REGISTRAR (M0. O W.)
<br />.JAN' 16 2014
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA'DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. •
<br />DATE OF ISSUANCE
<br />01/21/2014
<br />LINCOLN, NEBRASKA
<br />2014021 20
<br />STANLEY S. COOPER : •'
<br />ASSISTANT STATE REGISTRAR
<br />pEPARTIOIT'9� E 1LTH AND
<br />HO/MAN SERVICE •
<br />•
<br />STATE OF NEBRASKA - DEPARTMENT of HEALTH AND HUMAN SERVICES
<br />14 20152
<br />
|