|
STATE OF NEBRASKA 20 2 .1.(? -4,0 9
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTHA'Ub JA1 l'f
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THENEBR4$' tPj#�t41
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FORM/ RQRi35�r'
<br />DATE OF ISSUANCE
<br />12/23/2013
<br />LINCOLN, NEBRASKA
<br />i
<br />T NLEY
<br />dI SSIS7
<br />DEPMTME
<br />.HyM,4jV. S
<br />rCES, IT CERTIFIES
<br />EALTH AND
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEM
<br />CERTIFICATE OF DEATH
<br />To be completedherifled by: FUNERAL DIRECTOR I
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Gareth Eugene Brown �
<br />2. SEX , d -. <
<br />Male •
<br />pS,,likli`QFOEi1TH (MO., Day, Yr.)
<br />"'ligilZontier t2, 2013
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />Ib. UNDER 1 YEAR
<br />6c. UNDER 1 DAY
<br />0. DATE (*MIMS (Mo., Day, Yr.)
<br />Greeley County, Nebraska
<br />(Yrs.)
<br />85
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />September 5, 1928
<br />7. SOCIAL SECURITY NUMBER
<br />507-38-6112
<br />8a. PLACE OF DEATH
<br />nom. El Inpatient QIl(Eg 0 Nursing Home/LTC • Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Saint Francis Medical Center
<br />0 ER/Outpadent 0 Decedent's Homs
<br />❑ DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />94. STREET AND NUMBER
<br />617 North Custer
<br />9e. APT. NO.
<br />$f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />I; YES 1 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
<br />Ruby Ann
<br />SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Carr
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />James Eugene Brown
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Neva Trump
<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 />Ruby Ann Brown
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16. METHOD OF DISPOSII1ON
<br />® Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />16b. LICENSE NO.
<br />1071
<br />18c. DATE (Mo., Day, Yr.)
<br />December 19, 2013
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />184. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stab)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />1
<br />CAUSE OF DEATH (See Instructions and examples)
<br />To be completed by: CERTIFIER
<br />111. PART I. Enter the LWID of events -diseases, InluriN, or compllcatlons4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, •
<br />respiratory almost, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ma. Add addltio,W Vase N necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Respiratory Failure
<br />disease or ca•oblien resulting
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />2 Weeks __
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: ..; onset to death.
<br />Sequentially gar conditions, N b) Pulmonary Fibrosis t 2 Years
<br />any, leading to the muss listed I
<br />1
<br />line
<br />on a.
<br />DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />Ender the UNDERLYINO CAUSE c) I
<br />initiated
<br />(disease or injury that initiated 1
<br />the event. resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />LAST d) I
<br />I
<br />I
<br />18. PART II. 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 CONTACT?
<br />❑ YES 1'.I NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within put par
<br />❑ Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Naomi 0 Homicide
<br />0 Accident 0 Pending Invetupetion
<br />21b. IF TRANSPORTATION INJURY
<br />0 relver10perator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />0 Not pregrmast but urea 43 days to 1 year felons death❑salad.
<br />0 Unknown If pregnant within the past year
<br />❑could not M tlsbmdree
<br />0 Pedestrian
<br />❑Otter (Specify)TO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />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 sits, 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 />t 1
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 12, 2013
<br />a
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />1 iDecember
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />16, 2013
<br />23c. TIME OF DEATH
<br />09:25 AM
<br />4 g
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />1
<br />270. To tie lest a mY knowledq, death oeeunsd a tM time,deu end plea ,
<br />end due to ale muss(•) ehtee. @ignawe and TNM)
<br />Gary Settje, MD
<br />r3
<br />a
<br />Us. On tie Mab of exeminalon and/or Invealgadon, In mry opialon *Wm occurred at
<br />Mace and due to cause(s) stand (Signature and Tale)
<br />the time, date and Pise
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES Ii J NO 0 PROBABLY 0 UNKNOWN
<br />28a. HAS ORGAN ORTISSUE '
<br />0 YES r
<br />TION BEEN CONSIDERED?
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable N 28a Is NO f YES 0 NO
<br />27. NSA .IE, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Gary Settje, MD, 2116 W Faidley #400, Box 9802,
<br />Grand Island, ebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE 4.
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 18, 2013
<br />
|