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<br />STATE OF NEBRASKA
<br />s
<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 />2/1� Zf1iO I/�IIVCE
<br />LINCOLN, NEBRASKA
<br />RUSSELL FOSLER
<br />2 018 0 8 318 A DSTATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Mary Elizabeth Clark
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />February 25, 2010
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Hastings, Nebraska
<br />(Yrs.)
<br />81
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />January 3, 1929
<br />7. SOCIAL SECURITY NUMBER
<br />506-28-7463
<br />8a. PLACE OF DEATH
<br />HOSPITAL © Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Saint Francis Medical Center
<br />0 ERJOutpatient 0 Decedent's Home
<br />0 DOA 0 Other(Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />507 W. 16th
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL. STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Ron Clark
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Francis Earl Dickerson
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Gertrude Burroughs
<br />13. EVER IN U.S.ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No "
<br />14a. INFORMANT -NAME
<br />Ron Clark
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Tracey Dietz
<br />16b. LICENSE NO.
<br />1328
<br />16c. DATE (Mo., Day, Yr.)
<br />March 1, 2010
<br />❑ Cremation 0 Entombment
<br />❑,Removal . 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />ADfel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />fa. PART 1. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines 6 necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Respiratory Failure
<br />ait-asa or coed -tion rc,.,.,,;.tg
<br />onset to death
<br />3 Days
<br />in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b) Metastatic Ovarian Cancer
<br />any, leading to the cause listed's`
<br />on line a.
<br />onset to death
<br />..
<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 in death) q DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART ll. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑YES ;®NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident ❑ 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 />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 unknown if pegnarrt within the pest year
<br />0 Suicide 0 Could not be determined
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL CERTIFIER ..
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 1
<br />February 25, 2010
<br />To be completed by
<br />CORONER'S PHYSICIAPI.
<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 />February 26, 2010
<br />23c. TIME OF DEATH
<br />06:40 AM
<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 />and due to the cause(s) stated. (Signature and Title)
<br />Jennifer L. Brown, MD
<br />24e. On the basis of examination and/or investigation, 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 />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR DONATION BEEN CONSIDERED?
<br />❑YES 7
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jennifer L. Brown, MD, 729 North Custer Avenue,
<br />Grand Island,Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE JO-
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.}
<br />March 2, 2010
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