|
STATE OF NE.._.BRASKA
<br />re,..u..,: > 4bt11:tfftfDFS�>�::: �<:e- n r am> •ivr,461AyffffftSFszT° - •:•yet55mp,t8.wl��
<br />IS COPV:C AR#t!I'ES rkfg RASED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW
<br />OECOPYJOF.7141,0RIGINAL. RECORD ON FILE WITH THE NEBRASKA DEPARTMENT QF HEALTH AND
<br />!RVWCES i 1tAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATI opts A
<br />Kay;:` Brijkei'
<br />ATE' OR TERRIT
<br />j2O25O4864
<br />kik
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGIS
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE QEAT�1
<br />Ie, Last, Suffix)
<br />Y,.0li OREION COUNTRY OF BIRTH
<br />Nissans sburg iowa' "',.
<br />)CIAL SECURITY NLfSBES.
<br />II064.59 8' .'
<br />CtLITY.NAME"tlf`ibt tnadtudon, give street and number)
<br />an Isiend:Regonal..Medical Center
<br />c1V1 OR.TOWN`QF:OEATH;ins
<br />GrandIsland 66803
<br />4. REIIDENCE.STATE
<br />NgbraSka
<br />351.e ",sCtlttzSCI4ri4vt3lttie
<br />16m. MARITAL STATUS_AT
<br />© Married, but
<br />Ilep
<br />ATHE44AMEi.i1
<br />IN U S> ARMED'FORC
<br />o 'Or Unka) No
<br />00 OF 17(SPO0QNs
<br />sal'' :❑Da�iefott
<br />ludo Zip Code)
<br />9b. COUNTY
<br />Hall
<br />F DEATH la+ Married 0 Never Married
<br />owed © Divorced ❑ Unknown
<br />Last, Suffix)
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />75
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE QF DEATH
<br />HOSPITAL g} Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA'
<br />9c. CITY OR TOWN
<br />Grand Island
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maie
<br />-Terry John Bricker
<br />12. MOTHER'S•NAME (First, Middle, Maiden Sum
<br />LuEtta Ruth !burg
<br />HOURS
<br />MINS.
<br />3, DATE
<br />AO
<br />5. DA
<br />May/6.
<br />OVER ❑NursingMonte/.TC
<br />❑ Decedent's Hop04:-
<br />❑ Other (SpsCIf r)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Be, APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />14a. INFORMANT -NAME
<br />Terry John Bricker
<br />tsa.'FUNERAL DIRECTOR SIGNATURE
<br />Laurie D. Sheffield
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />TA UNERALHCM. NAME AND MA LUNfyi.ADDRESB (Street, City or Town, State)
<br />P')^Ip(rie, 2929 S. Locust Street, Grand Island, Nebraska
<br />i,.
<br />Ti. EtiMrtlM'c
<br />Ave CAtl:SE
<br />16b LICENSE NO.
<br />1397
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH Mee -Instructions and examples)
<br />Injuries, or complicationsih.t directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />tfleart showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines S necessary.
<br />CAUSE:
<br />emia
<br />E TO, Oft AS A CONSEQUENCE OF:
<br />in Overdose
<br />UNOERLYINe'4Aiiee ` C)
<br />• or injury t et IMtlated
<br />atswaujting in d.say' DUE
<br />'0.
<br />23i) 6** #3F
<br />UnkpOufe
<br />N
<br />GNII
<br />0, OR AS A CONSEQUENCE OF:
<br />R AS A CONSEQUENCE OF:
<br />NDMONS-Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />wMdtt 43 days of death
<br />t5 Mtya to 1 year afore death
<br />pdi, pact year
<br />oar,Yr)
<br />21a. MANNER OF OSATH
<br />❑ Natural ❑ Homicide
<br />0 Accident ❑ Pendinginv.itigatian
<br />® Suicide ❑ could not be detemdned
<br />22b. TIME OF INJURY
<br />Unknown
<br />21b. IF TRANSPORTATION INJURY
<br />0 arhasfOperator
<br />PNetnger
<br />0 Pedeloian
<br />0 Other (Specify)
<br />14b,t
<br />SOOus+;t:
<br />10c. o
<br />August,
<br />1
<br />V
<br />21c.WAS ANAU
<br />❑ YES
<br />21d. WERE A'
<br />TO COMR
<br />Oa
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construed.
<br />Home
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />tf inflicted
<br />it LI 11"J1JR`x ;S' REET i NUMBER, APT.NO.
<br />ra{idits,}S►ist
<br />23a, DATE OF DEATH (M
<br />August 4,
<br />2 OATE:31CiNEa(MO•,
<br />: gtrput4t.P 2Qt
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />06:20 PM
<br />thi'4pt.aiuly ktioxlerfge, Ream occurred at the time, eau and plan
<br />.. and dweto Usitieuseta) stated. (Stoneham and Title)
<br />• Mitchell D Hervert, MD
<br />DT a.A
<br />YE
<br />8
<br />l
<br />8
<br />STATE
<br />Nebraska
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME'
<br />2M, On tltt I MOie of examination and/or Instantiation, M lily
<br />the time, date and place and due to the cauee(e).Y41. (
<br />Q1jl Qgy IRI 26a. HAS ORGAN OR TISSUE DONAN BEEN CONSIDERED?
<br />YES ®NO
<br />AN, A E$ 6F`CERTIFIER (Typo or Print
<br />D, 353.3 Prairieview St, Grand Island Nebraska, 68801
<br />p
<br />y, Yr.)
<br />6UTE TO THE DEATH?
<br />lY ❑ UNKNOWN
<br />25b. WAS CONS!
<br />Not Applicable If 25e Is
<br />28b. DATE FILE
<br />August 20, 2
<br />
|