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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTME V
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH'?
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPO
<br />DATE OF ISSUANCE
<br />07/21/2011
<br />LINCOLN, NEBRASKA
<br />202301700
<br />r
<br />r
<br />S'ANLEY S.
<br />0' As
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH A k 4UMS1�J l
<br />CERTIFICATE OF DEATH ,; s
<br />To be completediverified by: FUNERAL DIRECTOR I
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffbc) r
<br />Mary Ellen Rupp
<br />. Jj/ '.:1".�®X,
<br />_.- LY FeWetY;1/4.‘4,.
<br />Iy� lfLJ 1`p
<br />y,14, 2011 - ...
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE • Last Birthday
<br />5b. UNDER 1 YEAR
<br />Sc I.INDEli 1 DAY
<br />8. DATE OP ; Yr.
<br />Omaha, Nebraska
<br />(Yrs.)
<br />71
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINI.
<br />January 25•,1940 ; ::
<br />7. SOCIAL SECURITY NUMBER
<br />508-40-9669
<br />8a. PLACE OF DEATH "_
<br />MEM 0 Inpatient gnu II Nursing Nome/LTC
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Tiffany Square Care Center
<br />0 ER/Outpatient 0 Decedents Home . _ .
<br />0 DOA 0 Other (Specify)
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH 1 4
<br />Hall
<br />ea. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />8c. CITY OR TOWN
<br />Grand Island
<br />ed. STREET AND NUMBER
<br />2822 Lakewood Cr
<br />Be. APT. NO.
<br />H. ZIP CODE
<br />68801
<br />�'
<br />lig, Il p4 DiTY t4tr ,.
<br />j _ [ Y. p NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ®Married 0 Never Married
<br />Q Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAMEOF
<br />Robert
<br />SPOUSE (Piet; MOWj a t) EU 19) Il1rlro. a mp lsh hank 1 ^
<br />Rupp 4 r •r
<br />11. FATHER'S•NAME (Firs Middle, Last, Suffix)
<br />William R Spencer
<br />Ti r:.._ ft ::s,
<br />12. MOTHER'S -NAME (Fist, Middle, ' Maiden Burnes* ` ,
<br />Agnes Steal `
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service B Yes.
<br />(Yes, No, or Link.) No
<br />14a.INFORMANT•NAME
<br />Robert Rupp
<br />'14b. RELAT1014041. '
<br />Hund' j ,,.,...) - y,
<br />1s. METHOD OF DISPOSITION
<br />Q Burial 0 Donation
<br />lea. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />181. LICENSE: NO.
<br />We: DATE ) ►- ' ... y
<br />Jul�r 15, 2011 ,' :
<br />®Cremation ❑ Entombment
<br />❑ Removal 0 Other (Specify)
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/ TOWN STAee..
<br />Central Nebraska Cremation Services Gibbon i .' ..
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />17b. Zip CCBe'.
<br />68801
<br />1
<br />CAUSE OF DEATH (See instructions andexamplesl
<br />To be completed by: CERTIFIER
<br />18. PART I. Enter the chain of events -diseases, Injuries, or compllcatlons•that directly caused the death. DO NOT enter terminal events such as cardiac wrest, 1 T * EIVTl ,IA ', -' 1
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one Dewe on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Anaplastic Meningioma
<br />disease or condition resulting
<br />onset deft
<br />6 Yew ` ' • , -•
<br />•+^-
<br />e
<br />In death);DUE TO, OR AS A CONSEQUENCE OF:
<br />sequentially list condhlons, if b)
<br />any, leading to the mese listed
<br />�•
<br />.... f r
<br />• .
<br />on Iia a. DUE TO, OR ASA CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or Injury that Initiatedthe
<br />drtstl[1(8 :.
<br />- 5....
<br />events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onsitlfateki: .
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting k1 the underlying cause given In PART L
<br />10. WAS4100101.
<br />ORCORONft •; 1 w•:
<br />Cl YDS, '� 12:1 NO
<br />20. IF FEMALE:
<br />® Not pregnant within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Ardent 0 Pending Inveatlgatlon
<br />21b. IF TRANSPORTATION INJIJRY42Ic.
<br />0 OftvadOMPater
<br />0 Passenger
<br />i�
<br />WAS AN AUhvrlY PEttF_, '!
<br />❑ YES ® WO L' ...
<br />}
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />El Not pregnant, but pregnant 43 days to 1 year before death
<br />t
<br />0 unknown n pregnant withinnthePast year
<br />0 Suidde 0Could not be determined
<br />0 Pedssttlae
<br />0 Other (Specify)
<br />�
<br />21d, WERE A JTOP E illifi 0$ /iuV%I I.E..
<br />To COMPIATIFOftOilli Of Int
<br />0Yes `�1NO:;-
<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, ceMYlsflpp ii to, . "
<br />..
<br />}_ i
<br />22d. INJURY AT WORK?
<br />❑YES ❑NO•
<br />•
<br />22e. DESCRIBE HOW INJURY OCCURRED ' -
<br />-
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP'QOD6-
<br />L'
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July 14, 2011
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ti
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />July 15, 2011
<br />23c. TIME OF DEATH
<br />08:06 PM
<br />II
<br />4'
<br />24c. PRONOUNCED DEAD (MD, Day, Yr
<br />24d. TIME PRONOYNCEDORA6
<br />-
<br />Eand
<br />`
<br />To the beet of my knowledge, death occurred at the time, date and pial
<br />due to the cewgsl stated. (Signature and Title)
<br />James W. Hervert Jr., MD
<br />_
<br />. 1 i
<br />a
<br />24e. On the baso of examination and/or investigation. in cry epiNon GAM te .
<br />the time, dote and place and dna to the cause(*) stated. (Signature and
<br />:
<br />25. DID TOBACCO
<br />0
<br />USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES INO ■ PROBABLY ❑ UNKNOWN I ® YES 0 NO
<br />I 28b. WAS Cl$ (s is _ .r` r%
<br />INot Applicable If 28a Is NO ., cjY $' jAt 11�, .. _;
<br />27. NAME, TITLE D AD • + •• S OF CERT! R (PHYSICIAN, HYS1CIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY A111TTTORNEY)
<br />James W. Hervert Jr., MD, 2115 N Kansas Avenue, Hastings, Nebraska, 68901
<br />(Type or Print
<br />v,,;
<br />28a. REGISTRAR'S SIGNATURE i A. �
<br />fwjy[_
<br />128b. DATE FILED BY RdlGtS RARtMet DS ,1Fni 4r
<br />1 July 20, 2011
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