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..WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TQ_*, "RUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE-Of -Of HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE L iif VV "OSI 1PIFOR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />LIAR 111, 199? STANLEY S COOI�`).(RECTOR
<br />LINCOLN, NEBRASKA BUREAU,oe,,- V =A''L STATISTICS
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALtH
<br />BUREAU OF VITAL STATISTICS v 1
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH (Month, Day. Year,
<br />BeverlyY Jean Ross
<br />iFemale
<br />March 21, 1992
<br />4. CITY AND STATE OF BIRTH Of not m US.A_ name country)
<br />5a. AGE - Last Birtnday
<br />R 1 Y
<br />6 DATE OF BIRTH (Month. Day. Year,
<br />�lC.�.. OF'iS
<br />_Sb.-
<br />- _ _.
<br />Hastings, Nebraska
<br />43
<br />March 14, 1949
<br />7. SOCIAL SECURITY NUMBER 8a.
<br />PLACE OF DEATH
<br />HOSPITAL Y7 Inpatient = ER Outpatient Z DOA
<br />505 -74 -5141
<br />OTHER Nursing Home _ Res,dence _ Other /Spec,fyl -
<br />Bb. FACILITY - Name Rt not institution, give street and number;
<br />Bc CITY. TOWN OR LOCATION OF DEATH
<br />80 INSIDE CITY LIMITS
<br />Be . COUNTY OF DEATH
<br />/specify Yes or No)
<br />I
<br />Bryan Memorial Hospital
<br />Lincoln
<br />Yes
<br />Lancaster
<br />9a. RESIDENCE - STATE
<br />9b COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />90. STREET AND NUMBER pncludmg Zip Code)
<br />INSIDE CITY LIMITS
<br />190
<br />(Specify Yes or No,
<br />Nebraska
<br />Hall
<br />Doni an
<br />Rt. #l, Box 99 68832
<br />No
<br />10. RACE - (e.g., White. Black, American Indian,
<br />11. ANCESTRY (a g.Jtahan. Mexican, German, etc.)
<br />t2 MARRIED. NEVER MARRIED,
<br />13. NAME OF SPOUSE (M wife. give marten name)
<br />etc./ (SpecMl
<br />I
<br />(Specify)
<br />WIDOWED DIVORCED (Speciyl
<br />White
<br />American 0
<br />Married
<br />Jack Ross
<br />14a USUAL OCCUPATION (Give kind of work done during most 141.
<br />KIND OF BUSINESS INDUSTRY
<br />1
<br />,
<br />Elementary or Secondary (0 -12) Cd lege 1 -4 or 5.1
<br />Of working me, even a refired;
<br />�I
<br />I
<br />11
<br />Homemaker 4
<br />Own Home i'=
<br />1
<br />16. FATHER -NAME FIRST MIDDLE LAST 17.
<br />MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />Edgar Lavern VanBuskirk
<br />Ruth Irene Che ne
<br />18. WAS DECEASED
<br />EVER IN U.S ARMED FORCESn 19.
<br />INFORMANT - NAME - MAILING ADDRESS (STREET OR R.F.D NO_ CITY OR TOWN. STATE. ZIPI
<br />(Yes, no, of unk.)
<br />(8 yes, give war and dates of services)
<br />No
<br />Jack Ross Rt. #19 Box 99 Doni han Ne 68832
<br />20a. BURIAL, Cremation,Removal,
<br />20b. DATE
<br />20c CEMETERY OR CREMATORY - NAME 20d.
<br />LOCATION CITY OR TOWN STATE
<br />Donation
<br />Burial
<br />March 25, 1992
<br />Cedar View Cemetery
<br />Doniphan, Nebraska
<br />21, EM L IGNATURE 8 L EN
<br />22 FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.D NO., CITY OR TOWN. STATE. ZIPI 68801
<br />9. oOZ
<br />Livingston- Sondermann F.H., 505 W. Koenig, G.I. Ne
<br />23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a(, (b), AND Ic0 I Interval between onset and death
<br />PART
<br />I
<br />I(,I Sub arac void hemorrhage 1 dad
<br />DUE TO, OR AS A CONSEQUENCE OF. Interval between onset and death
<br />it
<br />tbl presumed cerebral aneurysm
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to death but not related
<br />PART III IF FEMALE. WAS THERE A
<br />24. AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART
<br />PREGNANCY IN THE PAST 3 MONTHS'
<br />/ speciy Yes or NOI
<br />EXAMINER OR CORONER'
<br />p
<br />(specify Yes or No;
<br />Yes C No
<br />26a. ACCIDENT. SUICIDE. HOMICIDE, UNDET..
<br />26b. DATE OF INJURY /MO..Day Yr.)
<br />26c. HOUR OF INJURY
<br />260. DESCRIBE HOW INJURY OCCURRED
<br />OR PENDING INVESTIGATION (Specify)
<br />26e. INJURY AT WORK
<br />261. PLACE OF INJURY - At home, farm, street, factory.
<br />26g. LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE
<br />(specify Yes or No)
<br />office budding, etc. (Specify)
<br />no
<br />27a DATE OF DEATH iMO., Day. Yr.)
<br />28a. DATE SIGNED (Mo., Day. Yr.)
<br />28b. TIME OF DEATH
<br />March 21, 1992
<br /><r
<br />5�
<br />�_¢
<br />�_ 0
<br />271. DATE SIGNED (MO.. Day Yr)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (MO.. Day. Yr)
<br />280. PRONOUNCED DEAD (MOUrI
<br />10:45 A
<br />B��
<br />27d. To the best of my kn dgi g0th occurred at t e t e. ate pla and due to the
<br />28e On the basis of examination and a investigation. in my opinion oeatr occurred at
<br />g
<br />3 Q
<br />F�
<br />causelsl stated.
<br />c� b
<br />, the nme. date and place and due to the cause(s1 stated
<br />�}
<br />19 nature antl Tnlet► / t/ -
<br />Si nature anc Ttlej
<br />29a DID TOBACCO USE CONTRIBUTE TO THE DEATH' 30a.
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED'
<br />30b WAS CONSENT GRANTED'
<br />❑ YES O C UNKNOWN
<br />�<YES �: NO
<br />K-YES - NO
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICAN. CORONER'S PHYSICAN OR COUNTY ATTORNEY( /Type or Print)
<br />Eric W. Pierson, MD, 2221 So. 7th #310 o0t-i'h�coln NE 68502
<br />32a. REGISTRAR
<br />DATE FILED BY REGISTRAR (Mo.. Day. Yr
<br />r *A.. - 4�nA
<br />I
<br />1121,
<br />MAR s 0 1
<br />jqt -• --- - --
<br />
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