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STATE OF NEBRASKA
<br />r 'Y
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF1164L
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH 77-1E'�ME ,
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITOR -Y 13°
<br />DATE OF ISSUANCE
<br />05/18/2011
<br />LINCOLN, NEBRASKA
<br />STATE
<br />202006954
<br />AN SERVICES, IT CERTIFIES
<br />T OF HEALTH AND
<br />trt
<br />ST LEI' Sr, COOPER 4,
<br />AS TANT STATE1/iE6ISlrPAR
<br />-,,,' , ArTMENT:OFHE' TIJ 4ND
<br />HVfrj N SERVIG (.. r
<br />OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SE V)DEP Fir
<br />CERTIFICATE OF DEATH ' ` • J�1
<br />11 01638
<br />To be compleNd verMed by: FUNERAL DIRECTOR
<br />1
<br />1. DECEDENTS•NAME (Fink MlddIe, Last, Suffix)
<br />Carol Jean Seymour
<br />2. S 't •"ti -
<br />Female
<br />".DATE OF DEATH (Mo., Day, Yr.)
<br />> May 7, 2011
<br />4. CRY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ba. AGE • Last Birthday
<br />6b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Laurel, Nebraska
<br />(Yrs•)
<br />69
<br />MOS.
<br />DAYS
<br />HOURSMNS.
<br />I
<br />September 3, 1941
<br />7. SOCIAL SECURITY NUMBER
<br />508-54-8402
<br />81. PLACE OF DEATH
<br />11126E194 ❑ Inpatient gran 0 Nursing Horne/LTC 0 Hospice Facility
<br />Bb. FACILITY -NAME (Ir not Institution, give street and number)
<br />Saint Francis Medical Center
<br />IM ER/Outpatient 0 Decadent's Hone
<br />0 DOA 0 Other (Specify)
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />8a. RESIDENCESTATE
<br />Nebraska
<br />Bb. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />fid. STREET AND NUMBER
<br />213 Voss Road
<br />8e. APT. NO.
<br />81. ZIP CODE
<br />68801
<br />fig. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH Ill Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced ❑ unknown
<br />10b. NAME OF
<br />Jerry Se
<br />SPOUSE (First, Middle, Last, $uf lx) If wife, give maiden came
<br />our
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Joseph Turek
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Esther Stewart
<br />13. EVER IN U.S. ARMED FORCES? Glve dates of service M Yes.
<br />(Yes, No, Of unit.) No
<br />14a. INFORMANT -NAME
<br />Jerry Seymour
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />15. METHOD OF DISPOSITION
<br />El Burial 0 Donation
<br />16a EMBALMER -SIGNATURE
<br />Tracey Dietz
<br />lib. LICENSE NO.
<br />1328
<br />180. DATE (Mo., Day, Yr.)
<br />May 11, 2011
<br />o Cremation ❑Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />To be completed by: CERTIFIER
<br />IS. PART 1. Enter the EIMIj of events -diseases, lignites, or compllatloneahet directly caused the death. DO NOT enter to mini events such as cardiac arrest,
<br />IlbrdWtlon the DO NOT ABBREVIATE. Enter line. Add lines if
<br />APPROXIMATE INTERVAL
<br />mapkatory arrest, or ventricular without showing etiology. only one cause on a additional necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Pinta a) Gastrointestinal Bleed
<br />disease resulting
<br />onset to distil
<br />Immediate
<br />or condltlon
<br />in ds.tnl DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially Ila conditions, if b)
<br />any, leading to the cause listed
<br />gra
<br />onset to death
<br />on
<br />a DUE TO, OR AS A CONSEQUENCE OF:
<br />Erna the UNDERLYING CAUSE c)
<br />(disease or injury that Initiated
<br />onset to death
<br />the ennn re ninnn in dna") DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART IL OTHER SIGNIFICANT CONDITIONS•Condltons contributing to the death but not resulting In the underlying cause given in PART L
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES IZ NO
<br />20. IF FEMALE:
<br />® Not pregnant within pan year
<br />Pregnant death
<br />21a. MANNER OF DEATH
<br />I1 Natural 0 IloMclde
<br />21b. IF TRANSPORTATION INJURY
<br />0 DrWewOgretor
<br />Paper
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑vis ® NO
<br />o at tMte of
<br />o Not pregnant, but pregnant within 42 days of death
<br />o Na pregnant, but pregnant 42 1111M 10 1 year before death
<br />❑ Unknown If pregnant within the past year
<br />n
<br />0 Accident 0 Pending Imeedptlbsea
<br />❑swag. ❑ Could not a deamwed
<br />0
<br />0 n
<br />0 Outer (SWIM
<br />21d. WERE
<br />CAUSE OF DEATH?SY FINDINGS LE
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At hone,
<br />Tamm, street, factory, office building,
<br />con.truetion site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />122.. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />I'
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />a
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />May 11, 2011
<br />24b. TIME OF DEATH
<br />06:40 AM
<br />Y 23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />< g
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />May 7, 2011
<br />24d. TIME PRONOUNCED DEAD
<br />06:40 AM
<br />the but of my knowledge, death occurred at the time, date and plea
<br />24e. On baste dror MveMlgatlon, in death at
<br />f rTo
<br />,and due to the cause(s) staled. (Sp"ad"e and rite)
<br />3
<br />1-
<br />b
<br />to of aanNnatlon a my opbdom oawrretl
<br />the time, date and place and due to to cause(e) atated. ($Igname and TEM
<br />Martin Klein, Hall Deputy County Attomey
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES 0 NO 0 PROBABLY El UNKNOWN
<br />26a.HAS ORGAN OR TISSUE
<br />1 0 YES
<br />DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />123 NO Not Applicable if 26a Is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN,
<br />Martin Klein, Hall Deputy County Attomey, 231
<br />IAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY A EY) (Type or Print)
<br />S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />26a. REGISTRAR'S SIGNATURE A ' 128b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 17, 2011
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