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1. DICEDENf'l1NAMe (fret, ' Mottles, Lest, _ suffix)
<br />Violet Bernice Winfrey
<br />y,55n„l j' r�P1�i
<br />ta,4.t,41�i)t� :Q/��.�.Aiy1.1.1\Z,3at
<br />STATE OF NEBRASKA
<br />N0117:17Eintn! :: .aardmmy,
<br />'WFIEN : THtS4:: COPY CARRIES THE RAISED.' ;SEAL :OF :°::::.THE;, `STATE OF NEBRAS
<br />CERTIWfES;: ;THE DOCUMENT BELOW TO B;:::A TRUE :;iL'"OF':Y':;OF THE ORIGINAL R
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES,.
<br />RECORDS:N FFICE, WHICH IS THE LEGAL DEPOSITORY FOR;:VITAL RECORDS I �
<br />PATE gE SSUAI.OPE 2 V .5 U: ..:. .::.:
<br />7Y2$I2O1 9 or BEAM
<br />l81C STATE ii f1R. .
<br />LIMcOLN. NE.B.RASKA .. .: .: � ~ • AND K N ES
<br />*TATO!; OF NEBRASKA • QQPANTM NT QF'H ` TMM AND:I4UMAN SERVICES
<br />CERTWI;CATEOP ! EATH
<br />ttt`
<br />. CITY AMDATA L`OR ERR ITORY, OR 'PONIED COUNTRY OF BIRTH
<br />LIDCOIDeNaDr a
<br />T. SOCIAL SECURITY NUMEER
<br />! FACILr1 4IAME (If::.1Ret:irltrR(Itation, ohm Reboot and nun±bar)
<br />CHI t laalthi: t. Fran s
<br />so. OrrY OR TOWN OP DEATH (n * p Dodo)
<br />Grind.:lsland:. 08.803
<br />tli : REa KKIN..a3E TAT
<br />9d. STREET AND 'NURSER
<br />2 yyeat nth Street
<br />104. MAaITA. S:TATIJAAT TIME Os DEATH ® Marriott CI Navin Married
<br />Marra 4 IbuiIie `)il held :: Wtdovrad Divorced Unknown
<br />C1 ,:., Cl 0 0
<br />4x 'ACE 'R astEI th. y
<br />(Yra,)
<br />U ND R I. YEAR
<br />a),. P L,AGE OF DEATM
<br />HOIFITAL ISI Inpattllt
<br />EFUOUtinttlent
<br />CI DOA:
<br />FATHER'S N9NiI (li
<br />Clyde Luthultz
<br />MI
<br />1:3 11f*PUN.:U,$ ARMEDFORCEST Diva
<br />{Ye ►Do or t# } N
<br />1i MITH.OD:OP:DISP 1S(TION
<br />Buiiiai' Dantion
<br />0 Cramsdon Entombrn
<br />QRisnt*.I .' t')>hor(.:RP
<br />lb, COUNTY
<br />Mal{
<br />tOwm
<br />2.BEx
<br />Female
<br />So. UNDER i DAY
<br />HOUR§
<br />MINA,
<br />ATS OF 4S(AT
<br />ult l4,?r211
<br />OM © NunNnq Hom,A.YC.•
<br />0
<br />0 attar COMM
<br />C
<br />Hall
<br />TN
<br />h. APT. NO. if. VP QODE
<br />66801
<br />lob, NAME OF SPOUSE .(Flrt*t.. ;. Meddle, Lost, Suffix) It wick
<br />Caw, >; 1Nl:nfre;
<br />SR• MO'kliWI.NAME (Plrat MltRdle, Me111
<br />Venus Owen
<br />14a. INPORMANT.NAM..:::;.
<br />Doyle ::1A/infrev .:.'
<br />lac 3MpALMER.s1GNATURE
<br />Stacie L Ruiz
<br />ea 1f Yee.
<br />lid. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Ct metery
<br />17a FUN SRAL HOME' NAME AND MA t LNG ADDRESS (Street, City or Town, 8tatR)'.
<br />All Fpiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />#t?kk;:t.(CENSE NO.
<br />14©5
<br />CITY I TOWN ...
<br />Grand Island
<br />C6U)tQF DtAi`RJSje4 ingriketjona'Rd @amR)Df9s)
<br />:..#.ii>11ARr:1`GFinn Or W eW.ejls• 11isaaM#, in>whra Of eampikaeeneshat d)netly saudol;tla'ebath,, gDNp`FiingJa:ksrmiiiaa.: ellMinb owe es aortas* aerast,
<br />t, MIAtet,:!tit.Tr'Pi°s�.fn9d it,e lbrMMtion without shifting the etiology. DO NOT ARSR!VIAIS. Knee; oft anrcli cline en. a 1101 Add additional PM* a aHu4$i y
<br />� :. ATE M IMMEDIATE CAUSE;
<br />Di
<br />MMPtIA1'F CAUSE (Metal n) Urosepsis, myocardial Infarction
<br />dt#en* or gandkign rpulbtio
<br />to deauy
<br />Si,*liitetty t0 M4AAMtl .ir
<br />eny, Ia tdnrito lht p ria a lt0t11.d:
<br />en erne
<br />DUE TO, OR AS A CONSEQUENCE OF;
<br />b) Urinary Tract Infection,
<br />DUI TO, OR AI A Ci
<br />inter the tonnutLYNaG GAUsa 0)
<br />:.#gWoumar•iro r icat:lnittat tt::::
<br />Rho ayetMR ''attkn?ti•(!! •
<br />wit(
<br />fv►sT:: :
<br />QUINCE OF:
<br />::DUI TO, OR Al A CONIHQUENCI OP:
<br />:0)
<br />1a. PARTS. OMER $IGNIFiCANT CONDI
<br />€ ement(tt.. areY rre, Hyoethyrelaism
<br />R.Contlitione contributing to the dasth but not resulting In tit
<br />• Q Not pregnant ofithin rim•year
<br />0 aieartule ptonta d death
<br />Naf pripPen §ut proa.nato.yainfri 4Q Mtn at' aleath
<br />:Net ariaaii►rkbat Reanadt. demi to 1 veer before death
<br />CI•yit1uto as a en inerrt viltt :a*ke oast roar
<br />2a DATE OF INJURY (Me„
<br />1a, MANNER OF Dt3ATH
<br />Neturat © NOON* '
<br />*coition* 0 Pending hwMtlaetlM
<br />0stow.I+� 4rd44d;9dYha.dE}le
<br />0
<br />y, Yr,)—22b,TIME OF INJURY
<br />ing co
<br />se
<br />$lit`I 'T ' NaPORTATIONINJURY
<br />rirlwtrl@aaretar
<br />4,+ PresanQer
<br />',"!"Hare
<br />010.000eaNyi
<br />22c. PLACE OF INJURY.At home, fern, inset, faotery
<br />BE NOW INJURY OCCURRED
<br />OE. INJURY AT ?e DESiRI
<br />vs ..HD
<br />22f. LOCATION OF INJURY $TR*h1 i NUMIER, AFT.NQ,
<br />CITY/TOWN
<br />ITATE
<br />23a, DATE •O .08M$ (Mo„ Not, Yr.)
<br />4.01..14 2010
<br />)i. DA SIGNED (Mo.,Day, Yr.)
<br />July 1£a, 20i9
<br />230,TIME OF DEATH
<br />08:25 AM
<br />Ms, HAS ORGAN.:
<br />© YES
<br />24a. OATS 81GNED (Mo., Day, Yr,)
<br />NCED DEAD (Mo., Day, Yr.)
<br />24b,
<br />t.ATiihNQll)P
<br />'A 4470. N" A
<br />a> onse �
<br />e+ .
<br />iota than 2 HGU%$
<br />2M. On the Mai, or examination smear Invealgalbn, in Orly as alyd uMe iolarad at
<br />Me Min, dato and pine end doe to the tauNq) stated. *MM4lA and NM)
<br />UE.00NADON B.
<br />II NO
<br />:04NTRIlUTE TO THE DEATH? 7R TI
<br />N9 FR°BASIN 0 UNKNOWN
<br />27. NAME, IITLE AND ADbR SWOP CERTIFIER (Type or Print
<br />Jane A, MoOonp:Idi:,.MD, 800 N Alpha Street, Grand Island, Nebreak*,:138803.::..
<br />a,.:REG13TRA 'aia4.NATURE `
<br />2s, tab ToSAC
<br />a Yes
<br />CONSIDERED?
<br />WAa CO
<br />Not Applytable Ir 20t1 la NO
<br />tab. DATE FILED BY RIQt*TRA
<br />July 17, 2019
<br />
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