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STATE OF NEBRASKA
<br />72:Ny11r.
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<br />#ENi{! 1.44 : COPY CARRIES THE RAISED:: <;SEA ` 'op —Twit: ` T/iE •'STATE OF NEBRASKA,
<br />"''CERTIFIES :?TJ E `` DOCUMENT BELOW TO BE.':A .T•RUE COPV::`OF THE ORIGINAL RS
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, .tom
<br />. •RECORDS OFEICE, WHICH IS THE LEGAL DEPOSITORY;FOR:�VITAL. RECORDS
<br />2� . .5 .
<br />`;A,�iJE (7FiSSLfi4A1GE � ��JFRIAR
<br />� a,. 202504638 IS
<br />DEPARTMENT GE REAM
<br />LINGO N, NatflASKA
<br />Diet 11ern1ee Winfrey
<br />AND STATE o*' eorrQRY, OR
<br />ICOncAlst)r;
<br />AL $MCURIa
<br />0$-28-6O3 ..
<br />IL.iT+ -FAN (I}::t Ot:l
<br />fu
<br />AND HUMAN SERVICES
<br />$'rAfitS OF Nti<6RASKA • DUPARTMENT OF : 14EAVI4 AND HUMAN SIMMONS
<br />CERTIFICATE OF DEATH
<br />w. 3arrix►
<br />REION C,OUN1rtY OF BIRTH
<br />stre
<br />C CMt iltli 11: Fran is
<br />3P DEA[N Onak N dip east,)
<br />Q8.B.Ds
<br />RE1 FDEN0.E4TATE'.
<br />NRbtite•
<br />YtEET ANi NUM$
<br />tit Srtt
<br />. RITAL $TATU$; T:TIME OF DEATH ® ow)
<br />D`:Manisil bu*ae rinr iii [,}Widowed 0 Qh
<br />tl
<br />nd.:I$Ia
<br />1. FATi SR'$•N*Ma (FIi
<br />Clyde Luthultz
<br />VER;Ia).U,$i:AtlMEArQRCEf)T
<br />INf Nd Ot l)f?.t
<br />;1.EPQ$11'IQN
<br />Doir+►(iun
<br />Cromatlon Entombment
<br />Rstnq(!41 Qthaa'(3peclly)
<br />a. FU►RAL N!IE`NEAN
<br />All Filiiths Funerta iomt
<br />Etipir tlo
<br />00101r#tyitM:0
<br />ME0Lo1 CAU$p(first
<br />r gonfalon moult**
<br />Its aandbfku
<br />thIl:.pl�dsa:H
<br />@la
<br />.cou
<br />I1 II
<br />Never Marled
<br />ad 0 Unknown
<br />Last, $uMlx)
<br />Give dates of service 1f Yee.
<br />A
<br />. gMBALMER,IIGNATURE
<br />scie L Rui
<br />4>1A
<br />4o. INFI
<br />Doyle
<br />EMATORY
<br />lawn Cemetery
<br />s1:al
<br />4o. PLACE OF D104
<br />O$PITAL IMInpstlent
<br />ER/utptt)ont
<br />t. YEA
<br />ec:::G
<br />N.
<br />SIX
<br />Female
<br />all
<br />UNQEI! 1 DAY
<br />F4tlrllllill 2
<br />PAR 0 Numing Nom*A.
<br />© Dsuduniflt Nun,
<br />Dew (
<br />, ZIP CODE
<br />seSQ1
<br />10b, NAME QPSPQUSE (FOOL,:::Middil, Lost, Suffix) if Wit,
<br />ovvla
<br />i1d0310'il•
<br />�e. APT. NO.
<br />1a. MOTNER'$.NAME (First Mldlth, Msit111It S41rAI1RtlI
<br />Venue Owen
<br />MANT,NAME.:.;.
<br />Winfrey
<br />R OTHER LOCATION
<br />ADDRESS ($treat, City or Town, 8tatlr);
<br />, Locust Street. Grand Island, Nebraska
<br />area. er
<br />h,
<br />:1fElts . CENSE N
<br />1495
<br />and le
<br />g Q DMA'-1asp lustrootja a:3nd.t?NmDf9$)
<br />di McelY wurtSl the death; DO hicsifentoraiiffidnal mono such se mediae arrest,
<br />me tha etiology. D0 NOT ANNIDADhliii. InW oniy.:a'ne Moms ono Iina Add addhbnhl atnas tt mmHeaay.
<br />v
<br />IMMEDIATE CAUSE:
<br />a) Urosepsis, myocardial Infarction
<br />OR AS A CONSEQUENCE OF:
<br />Tract Infection,
<br />DUa fI7, OR A$ A 00N*EQU$NCE OF:
<br />I11.VINo 0A W t1 4)
<br />alit laeliil�d:
<br />. PA QTblllR SIQNIRICAI
<br />0. tlr'F l(MAt.E
<br />paer
<br />ussnt in gets of death
<br />Nefilatienorit,:sw stallions within 41 daas of mom
<br />Not erlisseaVau* seeteni U diwo a t veer before
<br />tanhn o w+at Pcotatio i' Wilidn etb Nat year
<br />T0m oR Aa A CON$IQUENON OP:
<br />NDITI
<br />tins to the doeth
<br />lit not rssultino to th
<br />2�1at. MANNERrO•�1F 01411I
<br />53 Noura, u NaiRYh, de ... .
<br />Aeoldent U Pentane Inweet)aslen
<br />0 $uaalde 9o41d:nmif Ib:misloniainod
<br />2
<br />a. DATE OF INJURY (
<br />IfAlt)R1� A;t:4alORta?:
<br />A
<br />N
<br />INJU
<br />„thllPo Yr
<br />Q
<br />b.
<br />T i NUMEE
<br />E OP INJURY
<br />INJURY 00
<br />APT.NQ.
<br />2e. PLACE OF INJURY•At hems,
<br />OITYrrOWN
<br />'ti..A..: DA , Yr.)
<br />.401 ::14 2012
<br />b. DATE IRONED (Ma:, Day. Yr.) 23e,11ME OF DEATH
<br />,#uJv 16, 2019 48:25 AM
<br />lid. To the beet of my koovMAgs, loom armored at Me limo, dab and pine
<br />and due to the onusa(a) Wend. (akenatura and tags)
<br />aaro'A> McDonald, MD
<br />..............
<br />IccO'UI:G
<br />TE'r0 THE D
<br />Y
<br />ND di) QF
<br />Jana::A, Mo11akd,.::M
<br />UNKNOWN
<br />HAS ORGA
<br />0 YES
<br />n In PA I.
<br />18: T'RAN$PDR'rATi
<br />'Oth tt eofory)
<br />, slat, factory, offoe b
<br />DA't'E'SIGNED (Ma,
<br />C PMif?I*OUNCED DEAD (Mo., Dsy, Yr
<br />fat. 0n the bash a m
<br />the dins, date a
<br />11 NA:
<br />'WHO
<br />` IN0
<br />(Type or Print
<br />pia Street, Grand Isiend :Nebraaka;,688Q
<br />0FEN'CONSIDERE
<br />tm. W
<br />Ape(
<br />1
<br />AP%RQKe ATE'
<br />m ono* MOO
<br />less then Y2 Hours
<br />a
<br />AV
<br />NO%
<br />
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