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<br />WHEN 0.#40:"COPY CARRIES. 'THE RAISED SEAL :9F THE •.STATE • OF NEBRASKA,
<br />CERTIFIES 'THE DOCUMENT BELOW • TO •BE 'A TRUE COP ' OF THE • ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, - VITAL
<br />:.RECORDS OFFICE WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS .00
<br />DATE O "ISS#IANCE USSELL FOSLE1
<br />5/28/2011 ASSISTANT STATE REGISTRAR
<br />LINCOLN. NEBRASKA DEPARTMENT OF HEALTH
<br />QC1VI11rlrii))NI '7.,,
<br />AND HUMAN SERVICES
<br />8RA8KA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1.OSCEDENT$•NAME (Pint, Mime, Last, >3Wrlx
<br />Jeanne Lorraine Blue
<br />4. CITYAND STAOR TERRITORY, 0R FOREIGN COUNTRY OF BIRTH
<br />T. 0Q0IAL SECURITY NUMBER
<br />eb FA�frNLITY NAME
<br />groutution. sow atn»t and number)
<br />Cavi Health
<br />st.'Pranals
<br />i Se. CITY OR TOWN RP DEATH (Tinge ZIP Coale)
<br />1 Grand :island:. 88803
<br />la. RE$1DSNOLETA
<br />lClrala
<br />id:STIREET AND NUMEIR
<br />804 E. Sunket Ave
<br />Ise MARITAL STATUS AT TIME OF DEATH Married p Nicer Married
<br />D Marded, f tseparubd` 0 Widowed p Divorced p Unlmown
<br />i
<br />6a. AGE Last
<br />(Yrs.)
<br />Blttltdey
<br />ib. UNDER* YEAR
<br />MOS. WAYS
<br />EL PLAGE OF bum
<br />NOVITAL In(rafont
<br />EB/Gi tpatient
<br />p,DOA
<br />2: 8lEX
<br />Female
<br />6o UNDER 1 DAY
<br />A DATE OP MATH (Me..
<br />Mev 19.2914
<br />1 DATE or eIRl1{4MO.,
<br />June 22, 19, 1
<br />satga 0 Nursing HameR.TB
<br />p Decedent's Hams
<br />p OSPH ISPooffY
<br />Id. COUNTY QP DSATN
<br />Hall
<br />iib. COUNTY
<br />Hall
<br />11, PATHIER'S.NAME '(Fila, Mid
<br />John L Jslinek
<br />I3:':6VER tri u S:ARM#D FORCES?
<br />(Yes; flOiA Ifnita N0
<br />18
<br />stitripp:obifil?OrION
<br />aw(el DenINon
<br />0 Cremation 0 Entombment
<br />Q RlxroNtal OINC ($peeify)
<br />1,
<br />)
<br />le.CiTYORTSWN
<br />0.:rtd :lend''
<br />teb NAME OF:IPOUSE,'(
<br />Kenneth J BR#e
<br />Give dells of service if Yes14a. INFORMANT•NAMB
<br />Kenneth #11,10
<br />131
<br />Stade L Ruiz
<br />Se. APT. NQ.
<br />ef. ZIP CODE
<br />68801
<br />Middle, Last. Suffix) If safe, EMI mdden ISM,
<br />12 MOTHER'S.NAME (First,
<br />Betty Demery
<br />led. CEMETERY, CREMATORY 0R OTHER LOCATION
<br />..
<br />Grand Island CIty Cemetery
<br />16b"LICENSE NO.
<br />1495
<br />Middle,
<br />CITY I TOWN
<br />Grand Island
<br />1
<br />47i..FUNE*AL 4600.14400 AND MAtUNG ADDRESS (Street, City er Town, atath).
<br />Ail Faiths Funeral Horrid: 2029 S. Locust Street, Grand Island: Nebraska`
<br />#S PARTi,IOWa
<br />I
<br />WastOATI CAUSE SIMI
<br />410m or condition rasuaing
<br />isi9eetut _
<br />Sgeorili.ay lea alone, a
<br />' 1.0*10 awes iss;)ra►4J
<br />ce:
<br />14b.' RELATIOMIT IP.TQ DE0*DENT'.:.
<br />Ht.
<br />STATS
<br />QAUSE OF DES Tr Ii ee in tryctIons and examolesk
<br />nilownee. Injuries, er /emtdiwaone het *reedy cawed as dealt, DD NQTenter+enigmi wens such es w,Ie anat.
<br />McRae* without 'Wane the MIe1 3y. DO NOT AOSION JAia, WNW enyk per slum on a lit* Arm additional Una a nasees.ry.
<br />IMMEDIATE CAUSE:
<br />a) Sepsis Due To Bowl Perforation
<br />88001
<br />DUE TO, OR AS A CONSEQUENCE 0F:
<br />16 Metastatic; Colon Censer
<br />DUI TO, WAWA
<br />*Or the Oloe*t vita WO* a)
<br />ESelietiintOrri.thitinithlted':;:
<br />rti' * ► DUE Ta oR AS A
<br />P:
<br />11 PART 11.OTHail SIONIFICANT
<br />-Conditions contributing to the death but not resulting in the underlying cause
<br />29•dF FEMAt.9s
<br />�j.Nat P:sewrlijul! reit rear
<br />p Pregnant etam.erdasm
<br />N41 n1 lies Pnsnnntwttirhh 4a 41ye or
<br />dace,
<br />trot pos9gi t,kwi liteinStit Awew 1 veer bonne 411th
<br />Cl`l nil w n if ichahsiKWhilli bre east year
<br />21a. MANNER OF DEATH
<br />® Noma 0 Hsmielde
<br />o Redden 0 Pending imasneatlon
<br />p Suicide 0. Collie not bo ohno red
<br />221 DATE OP INJi W' (Mo., Day, Yr.) •
<br />22b. TIME OP INJURY
<br />2
<br />9d.>INJUFIYATItltORKr 22e. DESCRIBE HON INJURY OCCURRED
<br />AYES pA10
<br />(TION 0?' INJURY - STREI 8 NUMBER, APT.NO
<br />23140*79 eF D9ATh (Moa. Day, Yr.)
<br />M t 1 ,.10419
<br />?Sb. DATE SIGNED (Mo., Day, Yr.)
<br />Mai x1.2019
<br />xaa To are bast or my knowledge, Aasdi occurred at the time, eat. and Plica
<br />antdUS litthe aam*n) ot.ted. pligionatJnd 71w)
<br />t.Id lY G is>lettenbrink, 00
<br />In P
<br />21b 1P .:'RANsPORTATION INJURY
<br />D41aaaperater
<br />0 Raaseap r
<br />p edeatAsn
<br />Ea 9lh** WP••*Y)
<br />i,
<br />11 WAS MIGNOAL a
<br />ON
<br />® Yat
<br />21a. WAS AN AUTOPSY'
<br />p Yom- NG
<br />PLACE OF INJURY -At home, farm, street, factory; ofna bull
<br />CITY/TOWN
<br />23o. TIME OF DEATH
<br />10;23 PM
<br />Est 010 TOSAr UtiaC w i nISt1 TO THE DEATH? 28e. HAS ORGAN OR IA'IOH 81141 CONSIDERED?
<br />D ilR11 NO .. PROMA1lfLY UNKNOWN p YES ®NO
<br />S.11TI AND AO SWOP C ERTIPI ('Type or Print
<br />Lkidtie+ C Mott nbr:ink, DO, 2444 W FaldlelAve, Grand laland, Nebraska,68803
<br />'esiR2018iRATt!18 81Ii11A#URE
<br />STATE
<br />Iii WERE AuToPevlontoos AAA114Ite
<br />TO OIRBPI.ITE OAUSSI9P 19>iAT
<br />® Yea p Ne
<br />in
<br />111
<br />1. DATE SIGNED (Mo., Dsy, Yr.)
<br />240. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />241x, TIME OF DEATH
<br />24d. TIME PeonpuNCED DEAD
<br />2N. On die Weis or Wminetion andrer hweeasaiien, kh.13
<br />the time, deb sae pied nod due to the saee.(e) stated.Teal
<br />essuireiet
<br />28b. WAS easaTiot
<br />Nat APpleabut if 20a ki NO. YE
<br />May 23, 2019
<br />
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