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ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE r. NAME: BRENDA KAY NELSON SOCIAL SECURITY NUMBER: 505 -94 -8446 PLACE OF DEATH: BISMARCK, NORTH MARITAL STATUS: MARRIED SURVIVING SPOUSE'S NAME: RICHARD L NELSON FATHER'S NAME: MOTHER'S MAIDEN NAME: RESIDENTIAL ADDRESS: PLACE DEATH OCCURRED: FACILITY OR ADDRESS: INFORMANT: INFORMANT'S ADDRESS: FINAL DISPOSITION: FUNERAL HOME: MEDICAL CERTIFIER: CERTIFIER'S ADDRESS: THIS IS TO CERTIFY THAT THERE IS ON RECORD IN THE DIVISION OF VITAL RECORDS, NORTH DAKOTA DEPARTMENT OF HEALTH, BISMARCK ND, THE FOLLOWING ENTRY OF DEATH: DECEDENT INFORMATION SEX: DATE OF DEATH: COUNTY OF DEATH: TIME OF DEATH: DATE OF BIRTH: AGE BIRTHPLACE: U.S. ARMED FORCES: IMMEDIATE CAUSE OF DEATH: as a consequence of > as a consequence of > as a consequence of > CONTRIBUTING FACTORS: MANNER OF DEATH: SUICIDE MEDICAL EXAMINER CONTACTED: YES AU TOPSY PERFORiM1ED: YES TOBACCO CONTRIBUTED TO DEATH: NO DECEASED DIABETIC: NO PREGNANT AT TIME OF DEATH: NOT PREGNANT WITHIN PAST YEAR DATE OF INJURY: PLACE OF INJURY: LOCATION OF INJURY: HOW INJURY OCCURRED: [ 001165347 North Dakota Department of Health Bismarck, North Dakota 2 KENNETH W . ELLIS CAROLYNI•LORANCE 577 COTTONWOOD LOOP BISMARCK, NORTH DAKOTA 5850 DECEDENTS HOME 577 COTTONWOOD LOOP BISMARCK, NORTH. DAKOTA 585 INFtJRMANT INFORMATION RICHARD NELSON 577 COTTONWOOD LOOP BISMARCK, NORTH DAKOTA 58504 DISPOSITION INFORMATION DAKOTA CREMATION SERVICE METHOD: BISMARCK„ NORTH' DAKOTA EASTGATE FUNERAL SERVICE BISMARCK, ND 58502 MEDICAL CA WILLIAM MASSELLO, DOH • MEDICAL EXAMINER BISMARCK, ND 585€11 ANOXIC ENCEPHALOPATBY HANGING BY NECK NOVEMBER 14, 2014 HOME 577 LOOP BISMARCK, NORTH DAKOTA 58.50 SELF•HANGING WITH BELT NOOSE ttt CERTIFICATION OF VITAL RECORD FILING, DATE: DATE ISSUED: CERTIFICATE NO: FUNERAL DIRECTOR: (LICENSE NUMBER: E OF DEATH INFORMATION LICENSE NUMBER: Darin J. Meschke State Registrar of Vital Statistics This certificate is issued in Compliance with the laws of the State of North Dakota (NOT VALID Without raised impression. seal of the North Dakota Department of Health) FEMALE NOVEMBER 16, 2014 BURLEIGH 12:15 APRIL 14, 1963 61 YEARS NEBRASKA NO NOVEMBER 19, 2014 NOVEMBER 20, 2014 133 -14- 005933 HUSBAND DOUG BROWN 11 1084 10589 TIME OF`INJURY: UNKNOWN INJURY AT WORK: NO TRANSPORTATION INJURY: AUTOPSY FINDINGS AVAILABLE: YES e R4