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1. DECEDENT'S -NAME (First, Middle, Last, SuRbl) 2
<br />2. SEX 3
<br />3. DATE OF DEATH (Mo.,Day,Yr.)
<br />4. CRY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5
<br />5s. AGE -Lest Birthday 5
<br />5b. UNDER 1 YEAR 5
<br />5c. UNDER 1 DAY 6
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />MOS. I D
<br />DAYS H
<br />HOURS M
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER t
<br />t)a. PLACE or DEATH
<br />0 ER4Outpatl.M 0 Decedent's Home
<br />6b. FACILITY -NAME (N net institution, Bias street and number) 0
<br />90. CITY OR TOWN OF DEATH (Include zip Code) B
<br />Bd. COUNTY OF DEATH
<br />ga. RESIDENCE -STATE 9
<br />9b. COUNTY 9
<br />90. CITY OR TOWN
<br />9d. STREET AND NUMBER S
<br />Se. APT. N0. 9
<br />94. ZIP CODE 9
<br />9g.I114SIDE CRY LIMITS
<br />10a. MARITAL STATUS AT TIME OF DEATH 110 Married ❑ Neva M 106. NAME OF SPOUSE (First, Middle, Last, Su/Po[) N wire, give maiden name.
<br />&Medi
<br />p Married, but separated Cl Widowed p Divorced ❑ Unknovm Georgia Lea wetter
<br />11. FATHER'S -NAME (First, MIddN, Last, Suffix) 1
<br />12. MOTHER'S -NAME (First, Middle, Malden Somme)
<br />19. EVER IN U.S. ARMED FORCES? Give data of service H Yes. 1
<br />14a. INFORMANT -NAME 1
<br />14b. RELATIONSHIP TO DECEDENT
<br />15. METHOD OF DISPOSMON 1
<br />16a. EM ER.SIGNAATU 1
<br />1 AI,/ M
<br />March N
<br />STATE
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 1
<br />17b. Zip Code
<br />CAUSE OF DEATH (See instructions and examples)
<br />1E PART L Enter the - e....aa InlurN., or campanile. m- dye. Madly nomad the BMA. DO NOT owe terminal manta wen to oaten erne. -, APPROXIMATE INTERVAL
<br />n.e.re.ry .71.t, or e.nbiwl.r abrniatIon wnhord ahaen9 Ow Madan. DO NOT ABBREVIATE Erdal. only one name on .Ilea Add additional En.. aratonaary.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Find
<br />disease or condition resulting a) III���� Eq. �' f ft fC n 1V,f 7 4+6 7 ,l ' ]'( w _ n _
<br />E�}
<br />! �
<br />M death)
<br />DUE TO, OR AS A CONSEQUENCE OF:: ! /� /16C-it Onset to death/
<br />Sequentially list a N
<br />, b, , E
<br />E F`it r
<br />(disease Or Injury that initiated onset to death
<br />t events renown In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />d)
<br />16. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given In PART 1. 1
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />p YES ❑ NO
<br />,,2,0)F. FEMALE: ,
<br />, 2 , 11a. MANNER OF DEATH 2
<br />21b. IF TRANSPORTATION INJURY 2
<br />210. WAS AN AUTOPSY PERFORMED?
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />22a. DATE OF INJURY (Mo., Day, TO 2
<br />22b. TIME OF INJURY 2
<br />22c. PLACE OF INJURY-At home, farm, street, factory, office building, ansuuctlon site, eta (Specify)
<br />22d. INJURY AT WORK? 2
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />224. LOCATION OF INJURY - STREET & NUMBER APT. NO. CITY/TOM ewe 8 "r".2
<br />4 M
<br />3a. DATE OF DEATH o., Day, yr.) 2
<br />Z 4 m
<br />24s. DATE SIGNED (Mo., Day. Yr.) M
<br />Mb. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.) 2
<br />23c. TIME OF DEATH O
<br />B 2 23d. T. the best of my knowledge, d
<br />death occurred e
<br />et the dm., date and plan 0
<br />0 w 24e.
<br />at th arm, basis of e B d na io n an dor Inves
<br />the ause(a1 my °Pinion nand ited
<br />,M, I
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 2
<br />29b. WAS CONSENT GRANTED?
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Steven G. Schneider. M D 830 N. RlphaS Grand Istcand J NE i$8o3
<br />26a. REGISTRAR'S SIGNATURE 2
<br />296. DATE FILED BY REGISTRAR (Mo, Day, Yr.)
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL Oc THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKAOEPARTMEIuT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL4tLECp S ;
<br />W
<br />Z
<br />LL
<br />3
<br />DATE OF ISSUANCE
<br />04/03/2015
<br />LINCOLN, NEBRASKA
<br />201601747
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICE
<br />ST,AN4EY S. CaQPER r <.
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTN) � "-3Fr}1EA'LTH -,4ND
<br />*1UPIAN RV ICES-
<br />1 2216
<br />
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