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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD 0Rf7LE1+ M -- THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECFL�iNa-WWti is - THE LEGAL DEPOSITORY FOR VITAL RECORDS. /_ DATE OF ISSUANCE• "U _ JAN 2 5 2001 200101203 ASSISTANT Mtt Rkd~--, LINCOLN, NEBRASKA HEALTH AND HUMAN SERVIC,£S- SYSTEIV, STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FNANCt AND SWPORT _ VITAL STATISTICS O O 3 3 S CERTIFICATE OF DEATH _ .__ I DECEDENT - NAME FIRST MIDDLE LAST 2 SEX 3. DATE'01� (Month Din Everette NMI Greenfield J r r4-7C T IT AND STATE OF BIRTH llfno[ n USA.. name country/ (Ages 10 -54) Yes No 5a. AGE - Last Birthday UNDER 1 YEAR UNDER I DAY 6. DATE OF BIR tMOnM. Day Year) Osceola, Missouri 26d. DESCRIBE HOW INJURY OCCURRED (Yr$I 5b MOS DAYS 5c HOURS MINS 85 ❑ Suicide n Pending 7 - CI SECIMTIY NUMBER 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Be . PLACE OF DEATH 497 -14 -7735 o8ic oaice MI HOSPITAL. © Inpatient OTHER. F-] Nursing Home — - - -- ❑ ER Outpatient ❑ Residence 8b FACILITY Name /Irnotmshfution, give streelandnumber) VA Medical Center DOA ❑ Other (Specdvi _ 8c CITY TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS Be COUNTY OF DEATH Omaha M Yes ®' NO ❑ I Douglas 1, RESIDENCE - STATE 9b COUNTY 4 y 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /including Zip Codel 9e INSIDE CITY LIMITS Nebraska Hal Grand Island gg° YeS� " °❑ 10 RACE - (e.g.. Whne. Black. Amencan Indian 11. ANCESTRY (e.g.. Italian. Mexican. German. etc) 12 ® MARRIED ❑ WIDOWED 13. NAME OF SPOUSE (ff wife. give maiden name) etcI So—ly) White (Specify) 1 American NEVER DIVORCED MARRI Grace V. Wade 14A USUAL OCCUPATION rG,ve kind of work done during most 141, KIND OF BUSINESS INDUSTRY 15. EDUCATION )Specify only highest grade completed) of work,nq life even d renredl Self Employed 29 DID TOBACCO USE CONTRIBUTE TO THE DEATH? Auto Body /Fender Repair Elemen or Secondary 10 -12) College n 4 or o- I 16 FATHER - NAME FIRST . MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME Everette �17 Greenfield Sr. Bertha Terry 18 WAS DECEASED EVER IN US ARMED FORCES? 32b DATE FILED BY REGISTRAR (Mo. Day Yr) 19a. INFORMANT NAME (Yes no ,, unk, fit yes give war and dates of services( Yes WWII 1/18/44 - 2/21/46 Grace Greenfield - 1 19b MFORMANT MAILING ADDRESS (STREET OR R F.D. NO.. CITY OR TOWN. STATE ZIP) - - I 1121 West 12th, Grand Island, Nebraska 68801 20 EMBALMER - SIG�N�AAT� 8 LICENSE NO 21a METHOD OF DISPOSITION 21 b. DATE 21c CEMETERY OR CREMATORY NAME /UfRE �//] 1 � - / � ® Burial ❑ Removal Jan- 8, 2001 F McPherson National a FUNERAL HOME NAME 61 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel- Butler- Geddes ❑ Cremation ❑ Donat,on Maxwell, Nebraska 22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIP( 1123 West Second, Grand Island, NE. 68801 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la) . IN. AND (cl) Interval between onset ann deal~ PART I (al As stole minutes r DUE TO, OR AS A CONSEQUENCE OF _ Interval between onset and oeath bI Respiratory failure -- - I minutes DUE 10. OR AS A CONSEQUENCE OF -. Interval benvean onset and dead` I 1�I OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY II IN THE PAST 3 MONTHS' EXAMINER OR CORONER' (Ages 10 -54) Yes No Vas No Yes No 26a 26b. DATE OF INJURY (Ma.. Day. Yr.) 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident F] Untlelermmed M ❑ Suicide n Pending 26e. INJURY AT WORK 261. EEWOF NNJLJRY % lgme, farm. street lacwry ,Id 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE F] Homicide Investigation Yes ❑ Nc ❑ o8ic oaice MI 27a DATE OF DEATH (MO.. Day Yr.) 28a. DATE SIGNED tMo_ Day. Yr l 28b. TIME OF DEATH J anuary 4, 2001 M 27b DATE SIGNED IMO. Day Yr) 27c. TIME OF DEATH 28c. PRONOUNCED DEAD (Mo. Day, Yr) 28d. PRONOUNCED DEAD (Howl 4 y y gg° January 11 2001 7:10 P. M s� o M 27d. To the Desl of my knOwle death occurred et M1e rime a and and tlue to the 288. On the basis andlor investigation, in death < place causal sl stated. /(�//E0/B�� j _ e n� ,(`-'/A_IJO� v V S of examination my opinion occurred at Me time. date and place and due to UM causes) stated. (5' nature and Title ► ( —�y (Signature and Title P. 29 DID TOBACCO USE CONTRIBUTE TO THE DEATH? HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED n 30.b WAS CONSENT GRANTED' 7a ❑ YES ❑ NO O UNKNOWN ❑ YES O NO YES ❑ NO 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type a Print) Kamron Khattak M. D., VA Medical Center, 4101 Woolworth Avenue Omaha NE 68105 32a REGISTRA 32b DATE FILED BY REGISTRAR (Mo. Day Yr) V- - U -