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WHEN THIS COPY CARRIES TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HU <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOR <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEC <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. x_ <br />DATE OF ISSUANCE _ <br />ANA Wit! <br />20010054EA <br />assIsraNr_a�AftR�4 <br />LINCOLN, NEBRASKA LT H AND HUMAN S# <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICF i MAN -C&A* <br />VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />.131 <br />I DECEDENT - NAME FIRST MIDDLE LAST <br />2 SEX <br />1 3.. DATE OF DEATH /Month. Day. Year) <br />Cheryl A. Nelson <br />Female <br />September 7 2000 <br />4, CITY AND STATE OF BIRTH litnot it USA.. name country) <br />58 . AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH rMonth. Day Year) <br />Scottsbluff, Nebraska <br />"rsl 38 5b <br />March 4, 1962 <br />MOs DAYS <br />S HOURS MINS <br />7 SOCIAL SECURTIV NUMBER <br />Ba PLACE OF DEATH <br />507 -62 -1325 <br />HOSPITAL ® Inpatient OTHER 0 Nursing Home <br />F-1 ER Outpatient F-1 Residence <br />8b. FACILITY - Name /B Trot institution, give street and number) <br />Good Samaritan Hospital <br />El DOA ❑ Other ISpecory) _ <br />8c CITY TOWN OR LOCATION OF DEATH Id INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Kearns Yes Y No ❑ <br />Buffalo <br />9a. RESIDENCE - STATE <br />9b. COUNTY <br />9c CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER /Including Zp Code) <br />9e INSIDE CITY LIMITS <br />Nebraska <br />Buffalo <br />Kearns <br />15 East 37th St. 68847 <br />Yes ® No <br />10 RACE (e.g.. White. Black American Indian. <br />11. ANCESTRY le .g.. Italian. Mexican. German, etc) <br />12. MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE Ilf wife. give maiden name/ <br />etc ISPe , <br />Wife <br />ISpecdyl <br />American <br />NEVER DIVORCED <br />MARRIED <br />Robert Nelson <br />14a USUAL OCCUPATION /Give kind of work done during most I <br />1 KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specify only highest grade completed) <br />of wonung life. even if retired) <br />Homemaker <br />Own home <br />Elementary or Secondary 10 -121 College I1.4 or 5-1 <br />j <br />16. FATHER - NAME FIRST MIDDLE. LAST 17 <br />_ _ <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />_ Michael Schafer <br />Leeann Hannon <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT NAME <br />Ives. no or unk l III yes give war and dales of s,,,c,,l <br />No <br />1 <br />Robert Nelson <br />19b INFORMANT MAILING ADDRESS (STREET OR R D NO, CITY OR TOWN STATE. ZIP) <br />15 East 37th St. Kearney, NE 68847 <br />20 EMBALMER - SIGNATURE 8 LICENSE NO <br />21 a METHOD OF DISPOSITION <br />211. DATE 21c. <br />CEMETERY OR CREMATORY - NAME <br />Not embalmed <br />❑ Budal F-] Removal <br />9/7/00 <br />Cent. Nebr. Crem. Serv. <br />22a. FUNERAL HOME NAME <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />O' Brien - Straatmann -Apfel F.H. <br />Cremation ❑ Donavon <br />Gibbon, NE <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO_ CITY OR TOWN. STATE. ZIP) <br />4115 Avenue N P.O. Box 2344 Kearney, NE 68848 -2344 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b). AND )G) I Interval between onset and deals <br />PART 1I 1, + ro f <br />s <br />I.) aIS I <br />DUE TO. OR AS A CONSEOUE14CE OF Interval between onset and dean <br />I <br />I <br />Ibl I <br />DUE TO OR AS A CONSEOUENCE OF Interval between onser and oealh <br />I <br />Icl � <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />PART <br />III IF FEMALE. WAS THERE A 24. <br />AUTOPSY <br />25 WAS CASE REFERRED TO MEDICAL <br />PREGNANCY <br />II <br />IY1v lfi I E Sc, i (l; 5', S (Ages <br />IN THE PAST 3 MONTHS? <br />10 -54) Ves No <br />Yes No <br />E%AMINER OR CORONER'1 <br />Ves No <br />26a <br />26b. DATE OF INJURY /MO. Day. Yr) <br />26c HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />Amitanl Undetermmed <br />M <br />Suicide F] Pending <br />26e. INJURY AT WORK <br />261. PLACE QF. INJURY - At home. farm. street. factory <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />H-1,de lovesugatmn <br />Yes No[:] <br />o ice bmldmg. etc lSpeafy) <br />27a DATE OF DEATH (Mo. Day. Yr) <br />28a DATE SIGNED (Mo.. Day. Yr) <br />28b TIME OF DEATH <br />- 7-60 <br />a <br />M <br />V <br />G i <br />T <br />270 DATE SIGNED (MO. Day <br />27c TIME OF DEATH <br />28c PRONOUNCED DEAD /MO. Day, Yr/ <br />28d, PRONOUNCED DEAD (Hour) <br />S <br />-7 <br />00 <br />;5 0 A M <br />o <br />z <br />M <br />o � <br />° <br />27d to the best of my knowledge. dea curretl at the time, date and place and clue to the <br />28e On the basis of examination and or investigation, in my opinion death occurred at <br />¢ ° <br />causes) staled. <br />° = <br />the time, date and place and due to the cause(s) stated. <br />ISI nature and Title Ilk ac <br />Signature and Titlel ► <br />29. DID TOBACCO USE CONTRIBUT T THE DEATH? 30.a <br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED'/ 30.b <br />WAS CONSENT GRANTED' <br />YES X NO 1-1 UNKNOWN <br />1:1 YES 12, NO <br />YES NO <br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY /Type or Print) <br />J.G. Haeberle MD 3907 th Avenue, Kearney, NE 68845 <br />32. REGISTRAR <br />32b. DATE FILED BY REGISTRAR (Mo.. Day Yr/ <br />S E P 11 2000 <br />