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1. DECEDENT'S -NAME (Fhsl, r Middle, Last, / Suffix)
<br />Cha .. Celestine Brown
<br />ris in
<br />2. SEX' a
<br />,Female
<br />3. DATE fWbEATH (44o., Day, Yr.)
<br />lune 3,,' 2010:
<br />4. CITY AND STkZO(TEdRITORY OR FOREIGN "COUNTFj,Y OF GIRTH
<br />Hasti:-i1 ' , NE'
<br />5p AGE -Last Birthday
<br />(Yrs f '" L
<br />61
<br />5b. UNDER 1 YEAR
<br />Sc - UNDER 1 DAY
<br />8: DATE OE BIR7 i (Mo., Day, Yr) - �4 +1
<br />} 7'
<br />F Feb': 1'7, 1949
<br />MOS. ';
<br />DAYS
<br />NOURS &
<br />MINS.
<br />. { iOGIA L SECURITY NU
<br />7 7.
<br />05,,58'-0��. --
<br />, "
<br />8a. PLACE OF DEATH
<br />: Inpatient HER: 0 Nursing Home /LTC ai Floaplce Facility
<br />HOSPITAL D OT
<br />-
<br />❑ ERroulpattent ❑ Decedent's Home ..
<br />❑ DOA - ❑ Other (Specify)
<br />FACE ME (If not kiilitution, glv�' number) - " --
<br />LT[
<br />- E
<br />_ � %? ..�'`1 `iH�45's@ - :.:.
<br />..
<br />- '
<br />9
<br />4
<br />'
<br />; '1 . t
<br />:CITY ORTtVr p do jir(clu d 66). /.
<br />K (J ' ,._.. 68'124
<br />ba. RE BIDENOf -ST T E !...
<br />k NE
<br />.
<br />� - _
<br />,Bb .-COUNTY , : _
<br />Dou:'las
<br />9c. CITY OR TOWN
<br />Omaha
<br />6d, COUNTY OF DEATH .....
<br />Douglas
<br />9d. STREET fr 4D'NU1(IBEF'.
<br />1043 So. 30th Ave
<br />9e. APT. NO
<br />91. ZIP CODE
<br />68105
<br />9g. INSIDE CITY LIMITS
<br />9 YES D NO
<br />•.: iF` 10a. MARITAL S "fATUS AT TIME OF DEATH ❑ Married ❑ Never Married
<br />I s: ,Cfm'aified,ifut separated 0 Widowed ' 12 . 1 Divorced - ❑ Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wile, give maiden name.-.,
<br />. 1 FATHER'S -NAME (First, Middle, Last, Sullix)
<br />Charlie,, D.,, McMillon
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Nellie M. Wells.
<br />$
<br />a r
<br />a
<br />kyY `
<br />i
<br />y
<br />t t ".
<br />13. ER IN U'S. ARMED FORCES? Give dgd h of service II yes.
<br />-. -
<br />1
<br />1(Ye no, aeIxdr ) " '
<br />14a. INFORM/WI-NOW
<br />i`Y.T k 9
<br />Saundra R. Clarke
<br />14b. RELATIONSHIP TO DLfCEDENT
<br />Daughter ° -
<br />15. METHOD l'' DISPOSITION
<br />rialx ru �bDonelbn
<br />C1
<br />A, ' 0 Cron orio:1 ,nbml8eenl i
<br />Remuyal 'tvadWavily)
<br />16a. E MER•SIGNATUR
<br />/ •' A t �
<br />, Y1 $- - )11
<br />•
<br />16b. LICENSE NO.
<br />� . ,
<br />16c. DATE (Mo., Day, Yr.4 -
<br />June 7, 2010
<br />tad. C. ETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE .
<br />Aurora Cemetery Aurora, NE.
<br />47a' L HOIviE NAME AND MAIL NO ADD S (Sheet, Oily or Town, Slate)
<br />T homa s Funeral H9iue, t , ,N 24th St , Omaha, NE
<br />((
<br />1 r .;: T ); \ ititifft.( 1lR C .i1lf Z
<br />18.-PART I. Enter the chain Qf wee* sasses, in)uf(as, or complications - -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE
<br />re iod arrest, or ventricular Iiyeil(atlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause an a line. Add additional lines If necessary. I
<br />•. CAUSE: I onset
<br />I ())04.)a.,- c,A.if\c..c.x. ,
<br />a Aal
<br />17b. Zip Code
<br />68110
<br />INTERVAL
<br />to death
<br />AT6 ' P Ofl A8 A CONSEQUENCE 61118E CAUSE (Eirwl
<br />dl§6adffi or co m on o . WE OF: - '. I onset to death
<br />t *INestth) I
<br />O b 1
<br />segdenllallyrMsteondltions, I onset to death
<br />If any, leading to the cause DUE TO, OR AS A CONSEQUENCE OF: I
<br />listed on line a. I
<br />Enter the UNDERLYING (c)
<br />CAUSE (disease or injury that DUE TO, Oil AS A CONSEQUENCE OF: 1 onset to d
<br />Initialed the events resulting I r .
<br />In death) LAST .. (d) . I , u .
<br />r ?
<br />z'.
<br />as ;,
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />, 1
<br />20. IF FEMALE:
<br />r ot pregnant within past year
<br />P regnant al time of death
<br />D Not pregnant, but pregnant within 42 days of death
<br />CI e Not pregnant, but pregnant 43 days 10 I year before death
<br />D Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />%i/I ural U Homicide
<br />Accident0 Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />U Driver/Operator
<br />D Passenger
<br />❑ Pedestrian
<br />U Other (Specify)
<br />21c. WAS AN AUTOPSY ' PERFORMED? 3i 'ti! l
<br />l" ' '
<br />❑ YES b
<br />21d. WERE AUTOPSY FINDINCy YAMS LE TO
<br />COMPLETE CAUSE OF DEATH?
<br />D YES U NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -AI home, farm, street, factory, office building, cons) uction site, etc. (Specify)
<br />22.. INJURY AT WORK?
<br />❑ YES ❑NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />4 :k
<br />221. LOCATION OF INJURY - STREET & NUMBER, 'APT NO. � CITY/TOWN STATE ZIP CODE
<br />a .,
<br />#fry
<br />+
<br />w
<br />E
<br />3 R O
<br />a O
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />( �1 3 U
<br />Z r
<br />� au
<br />' " z
<br />1
<br />E P az
<br />E w o
<br />a 0
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />235. DATE S1GFJE'D`" ''f- fi ' `'
<br />(0!
<br />` - 236. TIME OFT)FATH - ""
<br />) 'y�U m -
<br />24e. On the basis of examination and /or hives Igatfon, In my opinion death occurred at
<br />the time, date and place and due to the cause(s) staled. (Signature and Title ) •
<br />23d. To the best of my knowledge, death occurred at the time, dale and place :
<br />an due to the cause(s) staled. (Signalu 9 "and Title) ♦
<br />1T ,'
<br />25. DID TOBACCO USE CONTRIBUTE TO THE, DEATH?
<br />D YES ❑ NO ❑ PROBABLY ° UNKNOWN
<br />26a. (lAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />D YES D NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is no D YES D NO
<br />STATE F NEBRASKA - DEPARTMENT OF AND HUMAN SERVICES
<br />' CER FICAT O F, DEATH ' 't• 339623
<br />201603054
<br />27. NAME, TITL AND ADDRESS OF CERTIFIER P ICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY (Type or PrI rIA, _ /y- ` r(I r'
<br />28a. REGISTRAR'S SIGNATURE
<br />••••1
<br />286. DA FIL Y RE 1ST AR ( O � o,I Y ' .)
<br />This certifies this document to be a true copy of an original record on file with, Vital Statistics,
<br />Douglas Counfy Health Dept., Omaha, Nebraska. Certified copies must have a raised,,seal in the
<br />area to the left. Re of this green certificate are not legal copies. ' ' • JI
<br />Date Issued:
<br />.NN 18
<br />Registrar:
<br />
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