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<br />_STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, tT CERTIFIES THE DOCUMENT BELOW TO
<br />BE` A TRUE COPYOF THEORIGINAL RECORD ON FILE WITH THENEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICE ,VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />9/3/2022
<br />202206977
<br />SARAH BOHNENKAMP T _
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />" : 11 DEG DENTS -NAME (First, 'Middle, Last,
<br />Lett Witllarfl _Brewer, „
<br />Suffix)
<br />4. CITY:AND $TATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Burwell, Nebraska
<br />i, SOCIAL SECURITY NUMBER
<br />543.28.0347
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />• 8b. FACILITY -NAM]
<br />E • 202 Vine Street
<br />{Itnotinstitution, give street and number)
<br />„ CIT1r OR TOWN OF DEATH (Include'Zip Code)
<br />Alda 68810 `
<br />al 9a. RESIDENCE -STATE
<br />Nebraska
<br />9d STREETANDHIJMBER
<br />202 Vine Street
<br />86
<br />5b. UNDER`1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF Di?ATK
<br />HOSPITAL ❑ Inpaderit
<br />❑ ERIOu patient
<br />❑ DOA
<br />9b. COUNTY
<br />Hall
<br />i Sa. MARITAL STATUS AT 1IME OF DEATH MI Married 0 Never Married
<br />g0 Married but separated 0 Widowed 0 Divorced 0 Unknown
<br />FATNER'S NAIM (Itlrst Middle, Last, ' Suffix)
<br />George Robert Brewer
<br />3. EVER IN U•S: MtMED-
<br />ACES? Give dates of service If Yes.
<br />(Yes, No, orUnk)NO
<br />15. METHOD OF DISPOSITION
<br />{� Burial l] Donation
<br />E Q Cremation 0 Entombment -
<br />i . ❑ RBmova) , [Other(Specify)
<br />9c. CITY OR TOWN
<br />Alda
<br />10b. NAME OF; SPOUSE (First,
<br />Helen Alene Poling
<br />I1.2. MOTHER$-NAME'(First, Middle,
<br />Lourene Bonnie Connor
<br />HOURS
<br />MINS.
<br />11 03852
<br />3. DATE OF DEATki (Mo ..Day Yir) :,
<br />November l l k 2011
<br />6. DATE OF"BIRTH.(Mc., day Y!' );
<br />May 14, 1925
<br />OTHER ❑ Nursing Home/LTC
<br />® Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Middle
<br />9f. ZIP CODE
<br />68810
<br />9g IJ+ipoto*oo..s
<br />N47;'"
<br />Last, Suffix) If wife, give maiden name
<br />14a. INFORMANT -NAME
<br />Helen Brewer
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />18d. CEMETERY, CREMATORY OR OTHER LOCAT)ON'
<br />Central Nebraska Cremation Services
<br />to FUNERA(. HOE NAME AND MA LING ADDRESS(Street, City or Town, State)
<br />Kleine I"Unera( Home 3213 W. North Front Street, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />14b. RELATIONSH(A.'TO DECEDENT
<br />Spouse
<br />1 Bc DATE (Mo. Day Yr,)'
<br />November •t , 2£t
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH;(See Instructions And examples)
<br />8. PART 1. Enter the chain of.events- •tlieeasas; Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardlaC arrest,
<br />saplratory street, or ventricular fibriliationwithout Showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMtdEeIA+EOAI)s5(Pidal a) Chronic Obstructive Pulmonary Disease
<br />diseeak or toltdltil n i'esuRJng
<br />In deetip DUE TO, OR AS A: CONSEQUENCE OF:
<br />Sequentially list conditions, it b)
<br />any, leading tothecauae .:glad
<br />en ime'a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />TO, ORASA CONSEQUENCE OF:
<br />Nebraska
<br />1Tb. 2fp,Q
<br />00403F
<br />APPROXIMATE INTERVAL
<br />onset to daadt,.,.;
<br />40 years
<br />onset to death
<br />onset to death
<br />onset to
<br />18 PART II OTHER SIGNIFI ANtTONDITIONS-Conditions contributing to the death but hot reedit
<br />Corot /try Artery ii$e putmonary'Hypertension
<br />9IPfEMAIE
<br />❑ Not prega�nt witi#in Pact year
<br />FxmgrtamataUnaeidea� ':
<br />Nut pregnant, blit pregta3hF'within 42 days ries
<br />Not pregnant, but pregnenr 43 days to 1 year before death
<br />unknown H pregnant within the pest year
<br />220
<br />GATE O!<iNJUR((Mo.,,Dei, Yr.)
<br />21a.-ryMANNER OF DEATH
<br />5X1 Natural 0 Homicide
<br />Accident 0 Pending Tnveatigatlon
<br />0 Suicide - 0 Could not be determined
<br />in the underlying cause given In PART I.
<br />22b. TIME OF INJURY
<br />21b. IP TRANSPORTATION INJURY
<br />❑ OdverlOperator
<br />❑Passeager:��.^
<br />❑ Pedestrian
<br />0 Other(Specify)
<br />19 WAS MEDICAL EXAMINER
<br />OR Col NIR OeivokellsO?
<br />21c. WAS AN AUTOPSY PERFORMEI
<br />❑ YEs
<br />21 d. WERE AU1'OI)BY AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />CI -yes
<br />22c. PLACE OF INJURY -Al home farm, street, factory, office building, construction eNs, eta. (Specify)
<br />22d. INJURY AT WORK?
<br />DYES No
<br />22e.
<br />SCRIBE HOW INJURY OCCURRED
<br />LOCATION OF'INJURY : STREET 8. NUMBER, APT.NO,
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November. 11, 2011
<br />23b. DATE SIGNED (Mo., Day, Yr,) 23c. TIME OF DEATH
<br />Nou'Ehmber4\ 2011 10:15 AM
<br />3d. To 1195 beet oimyAnpw)adge, death occurred at the time, date and place
<br />and due to file cgttse(e) stated:(Signature and Tale)
<br />Larry L. Hansen. MD
<br />3. DIDTTBACCO.USECONTRIBUTE TO THE DEATH?
<br />❑ YES ❑ NO ❑PROBABLY IE UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH 'r
<br />24d. TIME PRONOUNCED DEAD
<br />toe. en'the basis of examination and/or Investigation, in my opinion death acaumtd
<br />the t mer date and place and due to the causes) stated.:. (Signature and.TM4r
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />NAM. E 1 E AHD ADOR555 OF CERTIFIER (Type or Print
<br />Larry L Hansen, MD, 3016 West Faidley, Grand Island, Nebraska, 68803
<br />28a. RE
<br />OOISTRAR'SSIGNATt1RE aivar"-
<br />is
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a is NO tom
<br />l��t! YEl
<br />28b. DATE FILED BY REGISTRAR (Mit„ Day, Yr.
<br />November 22, 2011.
<br />
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