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STATE OF NEBRASKA
<br />COUNTY OF HALL STATE OF NEBRASKA
<br />1, The undersigned ReglSter of Deeds of FSIPIHENTHISCOPYCARRIESTHERAISEDSEALOFTHENEBRASKAHEALTHANDHUMANSERVICES
<br />County, Nebraska, do hereby certify that this is SYSTEM, IT CERTIFIES THE BELOW TO BEA TRUE COPY OF THE ORIGINAL. RECORD ON FILE WITH
<br />true copy of the record of the original as the 6amWIE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTI ,$c$ egovFN_!CH IS
<br />appears of record in the office THE LEGAL DEPOSITORY FOR VITAL RECORDS`
<br />4n witness whereof I have hereunto set my hanTE affixed my official seal this •Le day TE OF ISSUANCE
<br />ne+ebpc o APR 2 3 2007 200705799
<br />Register
<br />Register of Dee
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<br />CDUNry
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<br />ASSISTANT WEREorS 04)
<br />HEJTHAND HUNAN SEIfIHCES
<br />202207704
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FM)IINCa' AND 9Or�T p
<br />CERTIFICATE OF DEATH • U 1 Q J O
<br />1. DECEDENT'S -NAME (Firer, Middle, Lain, Suffix)
<br />Vera Berdeen Hinkson
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day. Yr.)
<br />April 12, 2007
<br />v
<br />4. CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />S. AO E4,441 Birthday
<br />60. UNDER 1 YEAR
<br />02. UNDER 1 DAY
<br />e. DATE OF BIRTH (Mo., Day, Yr.)
<br />Hall County, Nebraska
<br />(Yrs.)
<br />91
<br />MOB.
<br />DAYS
<br />HOURS
<br />MINS.
<br />September 11, 1915
<br />7.SOCIAL 3t>cuamrA»,BER
<br />506-26-2001
<br />e,.PLACE OFDEATH
<br />HOSPITAL• 0 Inpetlerd am b Nursing Nome/LTC UHospice Wally
<br />80. FACILITY -NAME (11 not Institution, give street and number)
<br />Tiffany Square Care Center
<br />0 ERIOdpMMM 0 DecadHM's Moms
<br />O DM pOther (
<br />,d
<br />Sc. CITY OR TOWN OF DEATH (Inotsde Zlp Code)Bd.
<br />Grand Island 68803
<br />COUNTY OF DEATH
<br />Hall
<br />1T3S
<br />IBLREEIDENCE-STATE
<br />Nebraska
<br />eaCggnY
<br />Hall
<br />Bactrvowma#
<br />Grand Island
<br />;•: `i ,
<br />M. STREET AND NUMBER
<br />404 Woodland Drive
<br />Be. APS. NO
<br />70
<br />1N. ZIP CODE
<br />68801
<br />M. INSIDE CITY lBA1T8
<br />Xa YES 0 NO
<br />11 Ft)
<br />toe. MARITAL STATUS AT TIME Of DEATH T..) Herded ONever Herded
<br />0 Married, bul separated IX Widowed UDIvoroed OUnkawn
<br />10h. NAME OF 3POU8E(FlNI. Middle. Lad: Bullll011 wile give maiden name.
<br />'• ' •
<br />11. FATHER'S.NAME (First. Mlddie, Leat, Su1115)
<br />William Heupel
<br />12. MOTHER'S -NAME I Fine, Middle, Malden Surname)
<br />Bertha Pederson
<br />19. EVER IN U.S. ARMED FORCES? Give dates of service II yea.
<br />(Yes.naorunS.) No
<br />He.INFORMANT.NAME
<br />Brian Hinkson
<br />145. RELATIONSHIP TO DECEDENT
<br />Son
<br />16. METHOD OF DISPOSITION
<br />Qt5u0Hl UDon.Ro
<br />Hie. EM MER -81
<br />.
<br />IgA LICENSE NO.
<br />/349
<br />180. DATE (Mo., Day, Yr.)
<br />April 16, 2007
<br />O Cnmalion 1.1 Entombment
<br />05e111001 OOMx(Speciry)
<br />16d. CEMETE' , CREMATORY 0R OTHER LOCATION CITY 2TOWN STATE
<br />- .
<br />Cameron Cemetery, Wood River, Nebraska
<br />'1 y
<br />11Y
<br />�1yh�
<br />1
<br />:
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<br />L'_'a:•
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<br />11a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, CllyorTown, Stele)
<br />Apfel Funeral Home, 1123 West Second, Grand Island, NE.
<br />18 PART I. Enter Ile SRT.+d..oee,Nunes, mmmplicaBowmm dlndlycausedthe deem. D0 NOf•MerMune* event, such aserten tweet,
<br />net Oratory arrest, or venblouIer 11bnlMaonwMioul ehowing ms otology. 00NOT ABBREVIATE. Einer only one mwe on a line. Add eddNandlinu 0000. ..1
<br />BMAEOIATECAUSE:
<br />(R w 4aL .1 Ca are;)
<br />wMB01ATECAUSE nil
<br />APPROXMWTEINTEAVAL
<br />oriel
<br />,
<br />1?b. Zip Cede
<br />68801
<br />Indeath
<br />4:
<br />MK0.000Yllbll feHIVMg DUE TO, OR ABACONBC-0UENCE OF:
<br />In dab)
<br />A�
<br />SequenBMgENeereISne.B M /✓O 4(
<br />audio death
<br />any, te°S°5°"aaaYme4 DILE T0, OR AS A CIXNSEOUENCE OF:
<br />Whim
<br />Enewthe (dleeen OOlLYI GCAUSEted k1 �r4ybi.
<br />omen bdeed:
<br />B' se'wManMMYgMdNM) DUE TO, OR AS ACONBE°UENCE OF:
<br />IASr
<br />400444
<br />ousel to death
<br />19. PART HOMER SIGNWICANT CONDITIONS.CondltioneoOmMul ,51n the deathbui nolnMling intim underlying came given PART I.
<br />O. hp OA 1A4rIfi (CI A/ir.c
<br />(7
<br />It WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />O YE9 KR°
<br />20. W FEMALE: .
<br />❑ Not pennant within put year
<br />0 Preunanl at lime of death
<br />21a. MANNER OF DEATH
<br />trilateral °HomWds
<br />O AccidentC Handing Investigation
<br />210.1F TRANSPORTATION INJURY
<br />0orlv.n2ooaemr
<br />U PeeeefgM
<br />21c. WAS AN AUTOPSYPERFORMED?
<br />0 YES AMO
<br />0 Not pregnant, but prepaid MOIR 42 daysd death
<br />0 Nm pregnant, but pegnat e9 days et l year before deem
<br />0 Unknown II pregnant eats dm past year
<br />°Suicide °Could am be determined
<br />OPWauan
<br />O OM (SAWN)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSEOFgFAIN?
<br />0 YES ONO
<br />22a. DATE OF INJURY (Me., Oayy, Yr.)
<br />220. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -AI home, lane. greet, leetory, alma bulding, co elruelion site, Mc. (Specify)
<br />220. INJURY AT WORK?
<br />DYES ONO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />,..`
<br />9f3
<br />+
<br />A
<br />x1
<br />'a^
<br />22f. LOCATION OF INJURY • STREET 8 NUMBER, APT. NO. CITY/TOWN B1ATE ZIP CODE
<br />23a DATE OF DEATH (Mo., Day, Yr.)
<br />s �,Q g•, ( (2, 2f9a 7 al
<br />Zea Ds
<br />DATE SIGNED (Mo., illy,
<br />7$n
<br />�~
<br />2eb.TIME OF DEATH
<br />m
<br />► !Site DATE STONED (Mo., Day, 232 W 3 DEATH •E
<br />(�) m
<br />2Nc.PRONOUNCED DEAD (Mo., Dey,Vr.)
<br />2Ad.TME PRON011NCEDOFAD
<br />m
<br />6€sss[[[
<br />a=
<br />e line. end phos Bf 24e. On Meexamination or dealt In my opinion deoentredal
<br />° 23d.Tothe beald =and knOwlalpo. death alindem bllSS
<br />B • .� the l, date end ph. and deeloth camp) Haled. (Slgnaars and 7Ila)•
<br />and due ttootheeeue(s) stated(Signe(gneend Title ha
<br />et /410 a
<br />26.DID TOBA000U9E COHTR ETOTHE DEATH? /
<br />0 YES lj(io U PROBABLY 0 UNKNOWN
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES 'iZt NO
<br />286. WAS CONSENT GRANTED?
<br />NM A5PRcabe it 281 is NO 0 1E8 lit NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PNYSICIAN,CORONEW6 PHYSICIAN OR COUNTY ATTORNEY) PAH 0552.1)
<br />Gary Settje M.D. 2116 W.Grand Island, NE. 68803
<br />#400,;jr12.1,
<br />��F,a/idley1
<br />284. REGISTRARS SIGNATURE /�I.i'"-- A� A.
<br />286. DATE FILED BY REGISTRAR(MO., Day, YrJ/`APR 18 2007
<br />
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