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<br />2;I 1�h1111iii5;ntoNd� �j���ii�iiileGOc�✓.��..n: ���111.1.11.1,1,liii,..u4aila :au.urue/,rinr.65�Dri ���111),1.1./1,1,1/iG� ir,N.ena�buuuurE;Ep�rr,�AiNn,':�i�iilillrii�ijfem
<br />,.;�1��,i„;<;.. STATE OF NEBRASKA
<br />fj#11111 )t:x>MeJq:4r.G..9D.pMc,.•. �Eftlll,'I�Lf10@D.f:^.rs:??454t•QCJl3
<br />„!44/'I'I:CCPACtfJggr, ...%rtr,44�Pd.
<br />HEIif'"PHIS CLOP ">C RRI S THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />E.A TrnJE, COP OF rile. ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT 9F HEALTH AND
<br />(IMAN SERVICES, VITAL. RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />fin: r Q IsStlttr i
<br />9/1 l/2 i
<br />41N OL N NEBRAS
<br />202601570
<br />4.-�.t
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH'
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />AMID STATEQRTERRtTOtilt, QRPOREIGN COUNTRY OF BIRTH
<br />ratiktieralifskeraska 85 March
<br />t i1E4 U:RITYtitt 1R R 8a. PLACEOF DEATH
<br />' HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC
<br />FA ITY•ftAM (If lwt in►t[tutidn, pfve etreet and number) 0 ER/Outpatient 0 Decedent's Horn. .
<br />Nebraska M }d :::; ,' ❑ DOA 0 Other (Spaclfy)
<br />CIIY i1r .%:Q1 !!J':(?F.:,p ATFI Inchide zip Code) 8d, COUNTY OFDEATH
<br />0mha'68l8. Douglas
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5e. UNDER 1 DAY
<br />HOURS
<br />3. DATE
<br />9b. COUNTY
<br />Hall
<br />F'DEATH ❑ Married 0 Never Married
<br />Nllifaw,d 0 Divoced 0 Unknown
<br />9c. CITY OR TOWN
<br />Grand Island
<br />APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give
<br />;.; 1: .Piiii'fH R`s NA1Nl {First ;': Middle, Last, Suffix) 12, MOTHER'S -NAME (First, Middle, Maiden Sul
<br />m.,
<br />Ltrr(.'.`;:'Rktli::; ':::>:::'>:.: >r Ida Isabel Rice
<br />S=/1U bkVilMlEt`bQrfC) S9 ` 14a. INFORMANT -NAME 14b,
<br />ea, , o,Unk. No Jeffrey J Smaha S+
<br />4" I5.1 E7f#CD;OF DfSP'O$ITiON 16a, FUNERAL DIRECTOR SIGNATURE 1tlb. LICENSE NO. 18c.
<br />Sii#k#aI':1>tinaNaB:;::.
<br />' °'':•; :. laurie D. Sheffield 1397 / $�
<br />tian440'ttt
<br />�6d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />;f3thtir (Spero'
<br />F) N
<br />rand Island City Cemetery Grand Island
<br />1,!!'AND MA LING ADDRESS (Street, City or Town, State)
<br />I.lptrte, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />zfltart . gtr?Nr jjY avers##. diep#i rf, !Nudes, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, /
<br />tary sr ra tt; 9r vaMnCalitr flbrfNstion without showing the etiology. DO NOT ABBREVIATE, Enter only one csuse on a line. Add additional lines if neces4ary,
<br />flrlMEt IATE CAUSE:
<br />IF net >:;>> S IC -shock
<br />tod;libo i.isaanins:;""
<br />B) DUB TAS A CONSEQUENCE OF:
<br />OW:Srt;nrtdltoi il;; elBacteremia
<br />pil(tlytititiN'Ci1�eTaNii''"` . .,
<br />OR AS A CONSEQUENCE OF:
<br />ETO, OR AS A CONSEQUENCEOF:
<br />TiONPITIONS-Conditions contributing to the death but not resulting in the underlying.cause given in PART 1.
<br />pW,'aif#.st ttitlr'iN dlfsftt"'L>'
<br />Pregrtit ,tfut pr*gnim +ithin 42.days of death
<br />pregnanR talk prlgm4 43 dsys to 1 year before death
<br />ddvtu' 8 tlfig>fard v3Ntip'!(fs pant year
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide 0 Could not be determined
<br />Ib. IF TRANSPORTATION INJURY
<br />❑ Dnvar/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other(Specify)
<br />ohalrt/
<br />Au u
<br />19,-1MAS
<br />Old Ci
<br />21c. WAS AN AU1 OPSY:I El 1
<br />❑ YES
<br />21d. WERE AU1
<br />TO OWN.
<br />0 YES
<br />l }i '(Mb. 'Dey, Yi.} 22b. TIME 9P INJURY 22e. PLACE OF INJURY -At home, farm, street, factory, of fce building, con
<br />INJURY AT W4 RK? 2a., RISE HOW INJURY OCCURRED
<br />Oc AT3ON OF If1Jyl.FtY;.; ; TREET S NUMBER, APT.NO. CI17/TOWN STATE
<br />2IIt BATE OF DEATH. (Mo:, Day, Yr.) z 24a. DATE SIGNED (Mo.,Day, Yr.) 24b. TIME OF
<br />Septa r9,2E
<br />'x3b.:.DA E'$)GN ;:(Mo, Day;'Yr,) 23c. TIME OF DEATH1. ` 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d TIME P1k 1N1
<br />. r. i•5 2 25 09:50 AM
<br />hs#t'ot.tnYknOWiagga, death occurred at the time, date and piece " g Z 34a On the bads of examination andlgr investiga ion, in my apinion d S
<br />t . • amf di» fo lt'M'tauiiefil).#tated. (Signature and Title) B G g the time, date and place and due to the ne U(s)atated. {aipoltWU,.
<br />hrl$tppherJ, S>1'►ith, MD a
<br />t31I !(F' CB(l fE CTiNERt8U 7U THE DEATH? 26a. HAS ORGAN OR SSUE DONATION BEEN CONSIDERED? 28b. WAS CONSEAki'GRANT
<br />. YE$r.;: ISO?:'.. .: ROBABLY 0 UNKNOWN 0 YES 7 No Not Applicable if 26a is NO_'
<br />NAME; TITL AI D':K011RESS Ot_CERT'FIER (Type or Print
<br />llrlspher,,I. Smith, MD, 986453 Nebraska Medical Center, Omaha, Nebraska, 68198
<br />r r
<br />REGISTRAfl s. IC3NA'ri)RE 28b. DATE FILED BY REtif$TRAI
<br />_ A, ':),
<br />September 16, 3(�_{
<br />
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