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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 />