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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BEA TRUE COPY OF THE ORIGINAL RECORD,QN, FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC$.. peon. ; WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. �" a DATEOFISSUANCE JUN 0 LINCOLN, NEBRASKA 9 2008 • '-- NLEY'SrCOOPER ASSIFANT SiA�7G, REGIS1%9 HE4GtTH A.HgM4N,SERV • • may. , STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC@S F1N4I1 UPP ••• CERTIFICATE DF DEATH s n ei - •••••-• Sr„, 202107999 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Janette Poplau 2. SOX 'UL`i'I• Fame .", Tf,pPDEATH'(Mo.,Day,Yr.) 28, 2008 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Lest Birthday 5b. UNDER 1 YEAR Sc.UNDER tiDAX 8. DATE OF BIRTH (Mo., Day, Yr.) Edmunds County, South Dakota (Yrs.) 67 MOS. DAYS HOURS ,r�NIMS/ April 12, 1941 7. SOCIAL SECURITY NUMBER _> >) 503-48-7597 M. PLACE OF DEATH HOSPITAL: ❑ Inpatient 4THFJ# ❑ NursingHome/LTC la Hospice Facility Sb. FACILITY -NAME (If not institution, give street and number) 102 E. 17th Street ❑ ER/Outpatient I Decedent's Home ❑ Int 0 Other (y) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island, 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE 19b. COUNTY Nebraska I Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER .}, 102 E. 17th Street 9e. APT. NO 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS X YES ❑ NO 105. MARITAL STATUS AT TIME OF DEATH XMarried 0 Never Married ❑ Married, but separated 0 Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wile, give maiden name. Ray Poplau 11. FATHER'S -NAME (First, Middle, Last, Suffix) Bernhard Semmler 12. MOTHER'S -NAME (First, Middle, Malden Surname) Marie Leib 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. (Yes, no, or unk.) No 145. INFORMANT -NAME Ray Poplau 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION X uriai ❑Donation 16a EM= c.� , R -SIGNATURE `4 t4.-- 18b. LICENSE NO. 1092 16c. DATE (Mo., Day, Yr. ) Jun 2, 2008 ❑Cremation ❑Entombment CI Removal ❑ Other (Specify) A : 16d. CEMET flY, CREMATORY OR .THER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island NE 17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, State) , Curran Funeral Chapel 3005 South Locust Street , Grand Island, NE an.' .Y 17b. Zip Code 68801 18. PART!. 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 respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. I I IMMEDIATE CAU onset to death I tr ,� IMMEDIATE CAUSE (Final (M . r " " a') /e_. 4112 14 ` cu c,g/1" I .t disease orcorationresulting DUE TO, OR AS A CONSE ENCE OF: I onset to ath r �tn I In death) I Sequentiallyllst conditions, if (0) any, leading tote causetiabd DUE TO, OR AS A CONSEQUENCE OF:� I onset to death on lint a. c'-_-- I , Enter the UNDERLYING CAUSE (disease or injury that initialed (c) the events in death) . DUE TO, OR AS A CONSEQUENCE OF: i onset to death fn (d) 18. PART II.OTHER SIGNIFICANT CONDITIONS -Conditions contributingto the death but not resultingIn the underlying cause given In PART I. } x� Y 9 /� '�.1 V1e 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES I NO 20. IF FEMALE: ( a 4 a� ? Not pregnant within past year 21a. MANNER OF DEATH Natural ❑ Homidde ❑ Accident❑ Pending Investigation 21 b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES XNO MP,t Pregnant at time of death 0 Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Suicide ❑ Could not be determined ❑Pedestrian ❑ Other (Specify) _- - 21d.WEREAUTOPSYFINDINGSAVAILABLETO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO .,;. ❑ Unknown if pregnant within the past year _ ___. " 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) ri 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED a:rs, 1 " 221. LOCATION OF INJURY -STREET & NUMBER, APT. NO. CRY/TOWN SWE ZIP CODE }a ��. To be completed by Attending PHYSICIAN ONLY 23a. DATE OF DEATH (Mo.. Day, Yr.)Z b., 5 air� U� 11 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIME OF DEATH m 23b. DATE SIGNED (Mo., Day, Yr.) 23c.TIME OF DEATH lien .,' r m 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD m 23d.To the .est and duet of my knowle e, death rred a cau e( atetJ, (natu at the time, date and place $ upi � 24e. On the basis of examination and/or Investigation, in my opinion death occurred at a and Title) ♦ o gp .0 the time, date and place end due tome cause(s) stated. (Signature and Title )• 4 25.DID TOBACCO USE CONTRIBUTETO THE DEATH? 0 YES 10 ❑ PROBABLY ❑ U KNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES I NO 26b. WAS CONSENT GRANTED? Not Applicable 11265 is NO ❑ YES X NO $1 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Mehmet Sitki Copur M.D. 2116 W. Faidley Grand Island, NE 68802-9804 28a. REGISTRAR'S SIGNATURE Eft/�28b. DATE FILED SYREG T (Mo.bay,2808 U