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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH A„NO HUMA pi.SERV IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASK ` DEPARThENT OE nEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR WT4i EC©RDS ' _
<br />DATE OF ISSUANCE
<br />12/27/2013
<br />LINCOLN, NEBRASKA
<br />201505449
<br />S `ANLEY COOPER
<br />AS$ to �4GISTR;4l1
<br />D #PARTMEN bfr ir1E 4LTTH AND,
<br />HkIIMAfV SERVICC5
<br />fr
<br />1 DECEDENTS -NAME (Fist.:.. Mlddi0. Last. Suffix
<br />Audrey Ann Beck
<br />Battle Creek, Iowa
<br />50.:FACIIm-NMME (If not M INWIoI,gb.,tmtandlwmba,)
<br />Saint Francis Medical Center
<br />Ss. RESIDENCE-STATE
<br />Nebraska
<br />Id. STREET AND NUMBER
<br />2218 West 15th Street
<br />10s. MARITAL STATUS AT TIME OF DEATH ® Matirled >s ❑ Never 11
<br />Q. Monied, but separated Q W dowud :❑ Divorced : ❑Unknown
<br />11. FATHER'S-TAME (Fist,
<br />Milton Schmidt !'
<br />15. METHOD OF DISPOSITION
<br />Mound ❑lnanwM
<br />O C ,.. rl a . ❑
<br />CIS > 001hoMpudid
<br />17.. FUNERAL HOME NAME AND MASSIF ADDRESS (Nb•at. CUy or Town. Steal
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />t 29458
<br />2. DATE OF DEATH (Mo,Wy.Yr.)
<br />December 16, 2013
<br />M. UNDER 1 YEAR 6*. UNDER 1 DAY S. DATE OF BIRTH (Mo., Day, Yr.)
<br />April 9, 1932
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE Of DEJITH
<br />2. SEX
<br />Female
<br />20'., FEMALE: -''.
<br />01*610, OR ASA
<br />Enter the :UNDERLYINOCAUSE 4 _._
<br />(disease or k)ury that initiated
<br />ms warns row king M death) [ME TO, OR ASA CONSEQUENCE OP:
<br />LAST
<br />10.PART 11.OTHER SIONIPICANT DIONSCondRbns cotwbutlng to the death but not melting in She underyIna cause given N PART 1.
<br />1 4:4 A 1 4 131 4 2
<br />23a.DATE OF DEATH (MP. Day. TO
<br />December > > :16, 2013
<br />Mb. TIME OF INJURY
<br />222. DESCRIBE HOW INJURY OCCURRED
<br />21 MANNER OF DEATH 21b. IF TRANSPORTATION
<br />1 jNatural ❑ Homicide ❑ Driver/Operator
<br />❑ Accident ❑ Pending lmnedgatlon ❑ Passenger
<br />❑ Suicide ❑ Could not be determined ❑ Pedestrian
<br />❑OMNr (SpeeSy)
<br />220. PLACE OF INJURY -At home, rams, street, factory. office bulldkq, oanWdlon sit %sto. (100011 ) ::::
<br />STATE
<br />gas. DATE SIGNED (Mo.. Dog, Yr.) 240. TIRE OF DEATH -
<br />i APP r TB StTERVAL
<br />*eosin to death :.
<br />ZIP. CODE
<br />' � ' l . tat - `T ...,..AyrM,idwN., or eoao04Mid dingle" *mood dmddn. oar tommdmii•volde *doh as Arndt,
<br />wealrra.ravoid, rwrlrlda/MOAMAR wal,M aheaeytl..1*810 r. DO NOT AMMEVMR.ialr only owe a.w.ea aline. Add addm0*Y Ides tlaaoaaany.
<br />rI IMAEP4% CAUSE:
<br />Not pregnant wNhln pest yer
<br />QPregnam at time of death
<br />QNat pmpnunt, but pregnant 42 dysof death
<br />ONO Pregnant, but pregnant 43 days to 1 year before :d
<br />❑Unknown if pregnant' within tea past year
<br />225. DATE OF MRIRY(Mo., Dey. Yr.)
<br />1f. WAS MEDICAL: EXAMBRR
<br />OR CORONER ACTWT
<br />0 YRS N0
<br />bast of my knowledge, death oesorsd at the tints, date and piece
<br />to the eau i) wed. (Sig Return end Tide)
<br />24n. PRONOUNCED DEAD (Mo.,
<br />m
<br />24e. On the basis of esaminMisn and/or investigation, In my opkdon -death occurred
<br />et the time, date and place and duets the aaum(s) elided. (Sgmlai and Tip)
<br />2Ie HAS ORGAN OR TISSUE • -' TIGN: BUN CONAIDERROT :.:29b. WAS CONSENT GRANTED?
<br />:.: ❑YES Not Applicable N 26. is r10 Y65 a,l
<br />23b. SIDi1ED (Mo, Day, Yr.)
<br />ber 18 2013
<br />Grand Island, NE 68803
<br />AND ADDRESS OF CERTIFIER (Type or Print)
<br />Wagoner M.D. 800 N. Alpha Avenue,
<br />29e.REGISITRAR'S 6RRNATURE "`.
<br />16. EY8ALMHt4IONA
<br />CAUSE OF DEATH
<br />Se. A0B Last Birthday
<br />O
<br />1Sd, , CREMATORY OR OTHER: LOCATION
<br />Mount Hope Cemetery
<br />MOB. DAYS' HOURS MINS.
<br />9c. CtlYOR TOWN
<br />Grand Island
<br />Se. APT.: NO.
<br />See; Instructlens and exam
<br />fEBER:O Nursing H9sW1.TC : °Hospice Featly -.
<br />Q Desedenre Hann
<br />❑confM eo y)
<br />0*.2RP CODE
<br />.::.
<br />68803
<br />6nlbt) N wife, We =Man
<br />98. BLADE CITY UNITE
<br />® Ws 0 N
<br />tab. RELATIONI MP TODECD
<br />Spouse
<br />1ga. DATE (Mo, OW. TO
<br />December 21, 2013
<br />STATE
<br />Iowa
<br />17a Zip Cods
<br />68801
<br />
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