1€ DECIIDENT$4lAIN (First , (addN, Wit MOM
<br />Barbara Josephine Hammond
<br />2. S(X
<br />Female
<br />S. DATE Of DEATH(Mo,DagYc)
<br />October 8, 2012
<br />kart Aso STATaOR TERRITORY, ORFOniGN COUNTRYOPSlAm
<br />Ord, Nebraska
<br />TM. A081at
<br />(Ynl)
<br />63
<br />Mt. UNClR1YEAR
<br />de. UNDER 1DAY
<br />4.. DATE OF 112011 Pao, Deg, Yr.)
<br />February 22, 1949
<br />MOST l
<br />DAYS
<br />HOURS
<br />L MME.
<br />I Y. SOCIAL ssctwrr *NOM
<br />507-88 -1222
<br />W. PLACE Of DEATH
<br />10113/AL'. ® blpwwd 12111Ek Q Nuril; Holies LTC Q Hospdcs Facit
<br />0 °Decedents Home
<br />❑DOA p Deyn(3pedM
<br />Ib. PACllrY.3Y1aw<(Nnot ratieuVan. O..Y number)
<br />Nebraska Medical Center
<br />ec CITY CR TO0111 Of DEATH (bKYM. ZIpCods)
<br />Omaha 68198
<br />Ed. COUNTY Of DEATH
<br />Douglas
<br />sARESIDWICE.STATE
<br />Nebraska
<br />Sb. COUNTY
<br />Hall ;
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />Id. 51*1ST MO MAW
<br />320 Arapahoe Avenue '
<br />fe.APT.NO.
<br />sWZIPCOON ::
<br />68803
<br />5g. 515105 CITY LSITS i(
<br />® Yes ❑ N.
<br />10e. MARITAL STATUS AT TIME Of DEAN ®MsnNd ❑Nsw M.rd
<br />wed 0 Divorced p d d'own
<br />p Monied, but secreted 0 'Widowed 1M
<br />1014 NAME OP SPOUSE (P1rat Middle. Last SWen) Ewgw 9 06 "dm" name.
<br />I Rodney Hammond
<br />'II.FATfA211441111 (First 'ASdd.. Last. lulls)
<br />Alovze Osentowski
<br />12.M011E11!'E4AME(1kst. Middl, MaidenSWnente)
<br />tibi Pesek
<br />13. EVER IN U.S. ARMED FORCES? OIwdabs of ~Ace If VIII.
<br />(Y.a,No.«u,b.) No
<br />14. . INFORNAN4T40.411
<br />Rod Hammond
<br />lab. RELATIONSINP TO DECEOWIT
<br />Spouse
<br />,s ME,ltooafolSPOwttotl
<br />Mann we
<br />,IAE ,� �
<br />' ,
<br />; ( j
<br />,ebLwnaEV
<br />/
<br />lac ,a
<br />October 11, 2012
<br />CEMETERY 1ET RY, OROSR TH LOCATION CI YROWN STATE
<br />ML Hope Cemetery Sargent Nebraska
<br />CI«ealee Eseee.ent
<br />Onalevet a
<br />lb. FUNERAL HOME NAME AND MAILMIO AGGRESS (Street City or Town, Steel
<br />Rhoad Funeral Home, 207 N. 2nd Street, PO Box 310, Sargent, Nebraska
<br />1712Ip Code
<br />68674
<br />CAUSE OF DEATH (See Instructions and example!)
<br />II. PAWL Men the sNEataoggf • dl...... Ly dm oreaxelNi- 1•1A ayenrre srereel. DO NOT enNrlrrasal ewer aenl as mediae anent. :. I APPROXIMATE SITSFIYAL
<br />DO VDTANM 15M maw a saw Mesa oriel S,re+oowwry.
<br />,veessmry arm* wvnrrwrNS,wsleaMIMI ,IN' ow. eeM am
<br />i r
<br />61.11©441111 � �.l\ 'C1 ... ID
<br />MEDIATE CAUSE 5
<br />In disease s h) ndleoet+ard +) � s�9 j
<br />DUE To. ca .� Ipwstto
<br />: T '/''� r : I I
<br />e_ e ^I t .l <o}�Q "' .
<br />Sequoias 1y Wt conditions. If b) S y t �
<br />any, leading o the cause listed : Y
<br />on 305 a. D TO. it COWI IGEOP: +ons
<br />swatwe i.r
<br />sIWNG CAUSE 4) i h,... 0 -- 4 O �`' � : t c) u
<br />Misses* or Wary that
<br />the events resulting
<br />LAST
<br />lallitned
<br />Indesal) DUE TO. OR ASA CONSEQUENCE Oft
<br />6 (� G ( •,7
<br />1 onset* dsas •
<br />/ v �� , 2 . 5 - On
<br />11. PART U. OTHER SIONSICANT scoMreutinpb the death but not rssuling N his wIdudDNg cmi.. given hi PAR? I.
<br />Is. WAS7 AEDIC,AL SXAIMMA
<br />OR cO1W1lR CONTACTED?
<br />p vas ' 0 110
<br />X 20. W FEMALt
<br />IdrlWPregnannt within pest year
<br />°Pnsnalt et One otNeel
<br />°Notpe ast*,butpregantwihin42daysof dsYh :.
<br />0 Not present, tout pepnent42 days Nl yew before dealt
<br />Ounbeswn E pregnant within the pest year
<br />rtes OF DEATH
<br />a0NSb On
<br />QHdcbN
<br />0 Accident 0 PaMWg bwssspston
<br />0SukWe Could nut b.d.I. d
<br />3m. IF TRAPORTATION MUM
<br />t16
<br />0OAwNOpMnlor
<br />❑ Passenger
<br />0Pedabian
<br />0OIMr(spsdNI
<br />21c. WAS AN AUTOPPSYYPaWCMWt
<br />: ❑ yes &to
<br />21d. WERE AUTOPSY FINDINGS AVAAELE
<br />TO CoMPLETE CAUSE.OPDEATH? :;..
<br />, 0 YEA ,:0 NO
<br />22.. DATE OP INJURY (MO, Dey, W.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OP A RY.A1haw. tans. s Netory. Weal buMNq, wawcson spa, wt. (Dp•cIM
<br />22d. 'COURT AT WORKT
<br />13 YES 0 N
<br />22e. DESCRIES HOW INJURY OCCURRED
<br />22f. LOCATION Of INJURY - STREET* NUMEDt. CTTYROMIE STATE : 27P000E
<br />3m. DATE OF perm (Mo., Gay, Yr.)
<br />1 ' /0/ '/ 2 0/
<br />1"
<br />3
<br />J
<br />`�
<br />Ma. DATE MONO/ (Mo.. Day, Yr.)
<br />24b. TUN OF DEATH
<br />236 OAlI5101 0 (Mo., Day Yr)
<br />Iv, rn9/ iZ.
<br />23c TIME CF DEATH
<br />2o.oQt'm
<br />DEAD
<br />3,.. OnsNbaNd. n+ nnbrsonurdlorNwallSatlon .MnlYapildon aline accutr d . S:
<br />st In One, dale and place and due t o (Signature and TNN) -:
<br />23dToii. best « :. - 'etthe `deN
<br />my tbss, ndp4ee
<br />o and due* , rid Tile 3
<br />.. IM I!
<br />i
<br />2E DID T OEA00 USE come:SUTE tonal DEATH?
<br />A YES KNQ ❑ p'RO.AE*v ❑ u moveI
<br />IRA HAS ORGAN OR TISSUE 0 TION BEEN CONSIDERED?
<br />0 Yes Biro
<br />25b. WAS OONSENrervarED9
<br />[ Not Apps:01611 M N NO 0 YES
<br />3r. NAtiIE, 7m,E AJRt AOI�,RE3f
<br />1110 baba I
<br />Oslo'
<br />lea a M • 987i b i th asl�a. /n e e Te ma , � l �r ii9i
<br />7RARS atoNA
<br />31b DMTEfE20: Yr.)
<br />UC 12 2a1Z I
<br />.�,
<br />-` o ur
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF 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 NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />10/17/2012
<br />LINCOLN, NEBRASKA
<br />201706325
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 12
<br />CERTIFICATE OF DEATH
<br />27944
<br />
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