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STATE of NEBRASKA - DEPARTMENT OF HEALTH AND HLJl N SE 0 2 FINANCE 0075 <br />N 0 315971 <br />CERTIFICATE OF DEATH <br />1. DECEDENTS -NAME (First, Middle. last. <br />D eEtte Ruth Bran d <br />Sa. AGE -Last Birthday <br />(Yrs.) <br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH <br />Stromsburg, Nebraska <br />61 <br />Suffix) <br />2. SEX <br />Femal e <br />3. DATE OF DEATN (Ma. Day. Yr,) <br />January 1, 2005j <br />Sb. UNDER 1 YEAR <br />Sc. UNDER 1 DAY <br />MOS. DAYS <br />HOURS <br />MINS. <br />e. DATE OF BIRTH (Mo.. Day, Yr.) <br />February 19, 1943 <br />1. SOCIAL SECURITY NUMBER <br />505-48-1693 <br />Sb. FACILITY -NAME (II not institution, give street and number) <br />University <br />Nebraska Medical Center <br />I ea F1ACE OF DEATH <br />METAL: <br />3 inpatient Q 0 NurWg Home&TC O Hospice Fealty <br />O ER/Outpatient O Dscedwirs Wee <br />0 DM OOBmr(WY) <br />W. CITY OR TOWN OF DEATH (Include Zip Coda) <br />Omaha <br />M. COUNTY OF DEATH <br />Douglas <br />Se REST ENCS -MATE <br />Nebraska <br />90.00UNIY <br />Hall <br />se. CITY ORTOWN <br />Grand Island <br />66 STR11ETARDNWBER <br />4232 Nordic Road <br />se. APT. P40 <br />N. ZIP CODE <br />68803 <br />sg. INSIDE CITY WITS <br />to YES o No <br />10th MARITAL STATUS AT TIME OF DEATH XI Marded O Never Married <br />100. NAME OF SPOUSE (First. Middle, Last, Sul16t) N wile, give maiden ttaala. <br />Jerome H. grand <br />0 Mewled, but 0 Mowed 0 Divorced 0 Unknown <br />separated <br />it. FATHER'S -NAME (First. Middle. Lest, Suffix) <br />Henry Smith <br />12. MOTHER'S -NAME (First. Middle. Heiden Surname) <br />Jessie Covey <br />13. EVER IN U.S. ARMED FORCES? Give Oates of service if yes. <br />(Fae,ea,oraW.) No <br />Ira EIFORMANT•NAME <br />Jerome H. Brand <br />140. RELATIONSHIP TO DECEDENT <br />Spouse <br />15. METHOD OF DISPOSITION0 <br />21 Burial ODawlal <br />Ws. <br />n1(� G!P�((__Q� M�rA <br />100. LICE118E N0. <br />10b. <br />/�'f��- <br />a the DATE (5o., Day, 5 ) <br />January 5, 2005 <br />O c O etwon <br />100. CEMETERY, CREMATORY OR OTHER TION CITY / TOWN STATE <br />Westlawn Memorial Park Grand Island, Nebraska <br />.nstko ad <br />0Removst 0Ogier(Sp•clIy) <br />174 FUNERAL HOME NAME AND MAJUN G ADORESS (Street. City or Town. Sate) <br />. <br />. r r .. 1 at. 1 I e r r a If. <br />12. FART I. Enter thekqurte., Wooly Waft DO NOT APPROIdw1ATE <br />17b. Zip Code <br />..: i <br />INTENAIL <br />-dswsss, a complication -Mat caused the enter *mime events sat i M=ales anal, <br />Ibri2stlorl Ate DO NOT ABBREVIATE. Enter Inc Add Sees l <br />tespkaory West or wraklda without shoeing etiology. only one cane on a addllatel nao.Naryc <br />6.S.E. - ECAtME: onset toWMl <br />w (CUL/PG&E a-4-4‘4.1411 <br />IrMI®IATECAUNEIFtesl <br />deawveswlsateataffg <br />DUE TO, ORAS A CONSEQUENCE OF: i west to death <br />MOWS <br />u K <br />Sgr■wylist a 5+,{4 leu -4 C 47 c i ge K«O'J r / <br />dalssoae,S <br />1 <br />Noise <br />•t.dlseNOoawmum DUE TO, OR A CONSEQUENCE OF: I anal b death <br />an lbw& <br />Net theU10310110041111E <br />< CI. t <br />244 (& - O C? <br />v,gutP4 d NI 7'Q V.5)1 //lute S x IA <br />(dlaaaearN <br />meeser�reeaarl/M j DUE TO. OR AS A CONOUENCE OF, i mint le death <br />Ill <br />16. PART II. OTHER SIGNIFICANT CONDITIONS-Candlions contributing to the death but not resulting in the underlying awe given in FART I. <br />tAex / ( X 2_ <br />/ ' V _ / Q �, _/jam C4-1 <br />19. WAS MEDICAL EXAMINER <br />OR CORONER CONTACTED? <br />YES ONO <br />20. <br />Q <br />0 <br />0 <br />0 <br />0 <br />IF FEMALE: <br />14 <br />widen 42 days of dam <br />43 days to 1 year before death <br />the pest yea • <br />21st MANNER OF DEATH <br />�Ralursl O Homicide <br />0 Accident° Pending <br />O Suicide O Could not <br />Investigation <br />be determined detered <br />21 b. IF TRANSPORTATION INJURY <br />sr�e rator <br />0 Pumps' <br />0 <br />O other (Speedy) <br />21c. WAS AN AUTOPSY PERFORMED? <br />EV YES ONO <br />of pregnant within past year <br />Pregnant at time of death <br />Not pregnant. but prevent <br />Not <br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO <br />COMPLETE CAUSE OF DEATH? <br />® YES 0 NO <br />pregnantbut pregnant <br />ikirrosar if pregnant wslW1 <br />222. DATE OF INJURY (Mo, Day. Yr.) <br />220. TIME OF INJURY <br />m <br />22c. PLACE OF INJURY -At home, term. drat. factory, office buildng conetrucdon site, ale. (Specify) <br />22e.INJURY ATWONt? <br />D YES O NO <br />22s. ESCRISEHOWINJURYOCCURRED <br />2SLLOCATIONOFKIURY- STREET INUMBER, APT. NO. CITY/OM - SWE IOCODE <br />11 <br />23a.DATEOFDEATH (Mo.bweYr.) <br />f. <br />C\A <br />24a. DATE SIGNED (Mo,Owe Yr.) <br />iii <br />240.TI IEOFDEATH <br />23b DATED 1 0.OyrMtI * " • <br />g 1 1- ' . <br />i .i.0001OE <br />• . A . m <br />21e. PRONOUNCED DEAD (Ns. Doe Yr.) <br />��� <br />Tit TIE PRONOUNCED DEAD <br />m <br />I <br />260.Teahs L6i�qy 0 tt of aSmeffels and piece <br />and car* and TMte l • <br />24e.0n <br />. <br />12 II <br />I <br />be <br />then YwedM don <br />te of a em1narmt atria try r opinionam <br />doceuted al <br />the Wm, date and plea and due a M cause(s) slated (Signa um.Ad T0.) V <br />as.ODTOSACCO USE DEAMT .` sA " <br />0 YES , ✓ •, 0 � s'Oa1N1Al <br />2,..A3 ORGAN OR TiSSilE DONATION BEEN CONSIDERED? <br />YES C "NO <br />236. WAS CONSENT GRANTED? <br />Not Appllcable if 26. is NO 0 YES Zr/400 <br />MAIM_ TITLEatDaadEltS ms <br />0111712!t&21 Oa LINTY 11771N1EY1 Mos or PAM <br />260. DATE FILED BY REGISTRAR (Mo., Day, Yr.) <br />This certifies this document to be a true copy of an original record on file with Vital Statistics, Douglas County <br />Health Dept., Omaha, Nebraska. Certified copies must have a raised seal in the area to the left. Reproductions <br />of this green certificate are not legal copies. <br />Date Issued: JAN 13 20E6 <br />Registrar: <br />