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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />11/15/2018
<br />LINCOLN, NEBRASKA
<br />201807929 FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE f7F f)FATH
<br />18 14413
<br />1 Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the Bounty where the decedent resided at the time of death. I
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Carol Ann LaBrie
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 8, 2018
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE • Last Birthday
<br />Sb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Grand Island, Nebraska
<br />(Yrs.)
<br />74
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />September 20, 1944
<br />7. SOCIAL SECURITY NUMBER
<br />505-54-2619
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME Of not institution, give street and number)
<br />103 S. Buffalo Rd
<br />0 ER/Outpatient ® Decedent's Home
<br />0 DOA 0 Other(Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Doniphan, 68832,
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska '
<br />:
<br />9b. COUNTY
<br />Hall
<br />Sc. CITY OR TOWN
<br />Doniphan
<br />9d. STREET AND NUMBER
<br />103 S. Buffalo Rd
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68832
<br />9g. INSIDE CITY LIMITS
<br />0 YES ® NO
<br />40a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married 110b. NAME OF SPOUSE (First,' Middle, Last, Suffix) If wife, give maiden name
<br />❑Marled, but separated L0 Widowed 0 Divorced 0 Unknown I Robert Joseph LaBrie
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Melvin Sims
<br />1Z MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Leola Griffin
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Robert Joseph LaBrie '
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />0 0
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L. Ruiz
<br />16b. LICENSE NO.
<br />1495
<br />16c. DATE (Mo., Day, Yr.)
<br />November 17, 2018
<br />Cremation
<br />❑ Removal
<br />Entombment
<br />0 Other(Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Cedarview Cemetery Doniphan Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />ta. PART L Enter the chain of events --diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL'.
<br />respiratory arrest, or venttkcular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one causeon a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Squamous Cell Carcinoma Of Soft Palate
<br />disease or condition resulting
<br />in death)
<br />onset to death
<br />11 Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list Conditio na, if 'r b)
<br />any, leading to the: cause Rated'
<br />on line a.
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that initiated
<br />onset to death
<br />the events resulting m death) : DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />COPD, Hypothyroid, H/O Colon Cancer, Protein/Calorie Malnutrition, H/O Squamous Cell CA Esophagus
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES El NO
<br />20. IF FEMALE:
<br />® Not pregnant within past year
<br />❑ Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />0 Suicide ❑Could not be determinedTO
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />COMPLETE CAUSE OF DEATH?'
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)122b.
<br />TIME OF INJURY
<br />r 22c. PLACE OF INJURY -At home,
<br />farm, street, factory, office building,
<br />construction site, etc. (Specify)
<br />22d. INJURY AT WORK? 2
<br />❑YES ONO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />I Tobe completed by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 8, 2018
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />November 9, 2018
<br />23c. TIME OF DEATH
<br />03:50 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />anddue to the cause(s) stated. (Signature and Title)
<br />Kimberly A. Mickels, MD
<br />24e. On the basis of examination and/or investiga ion, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Kimberly Al. Mickels, MD, 729 North Custer Avenue,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE} C
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 13, 2018
<br />
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