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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE .COPY OPTHE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE QFISSUJiNCE"'
<br />3/162026
<br />LINCOLN, NEBRASKA
<br />20260 1f3
<br />Jimokunk
<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 />lirkew
<br />DEt EDENT`S NAME :{FIroiC: Middle, Last, Suffix)
<br />Moii*r ;lirgll da :Biala
<br />4. CITY AND STATE Olt TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Biloxi, Mississippi
<br />T sgC#AL SECURflYNUMeER
<br />425.44.6486
<br />CERTIFICATE OF DEATH
<br />5a. AGE - Last Birthd4
<br />(Yrs.)
<br />82
<br />.6 8b. FACILITY -NAME (N not Institution, give street and number)
<br />Tiffany:3gtiare Care Center
<br />8c. CITY OR TON(N OF DE .. (Include Zip Code)
<br />G rand . Isla red.: 68803
<br />I9a. RESIDENCE -STATE
<br />1 .• Nebraska
<br />• OM STREET AtIDNUMBER • :!;
<br />2915 S North Rdr
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Marled 0 Never Married
<br />9
<br />A❑ Monied, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11, FATHER'S.HAME (First. Middle, Last, Suffix)
<br />Sigsby Anderson Stokes
<br />k13. EVER IN'I.S:ARMED 'FORCES? Give dates of serve If Yes.
<br />(Yes, No, or Unk.) No
<br />1e..METHop:OF OISPOOTIO N
<br />❑ Hwlal ❑ DonetiFkk:i:
<br />®L`r•amWon❑Entorl#pment
<br />•❑ Removal ❑ Other (Specify)
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />8c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />12.00508:
<br />3. DATE OF DEAT'01(Ma., Day Yr
<br />February 15, 2012
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />January 7, 1930:':<'
<br />OTHER ® Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9f. ZIP CODE
<br />/ '68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Bonnard H Blair
<br />❑ HOIpice Facll ty
<br />14a. INFORMANT -NAME
<br />Bonnard H Blair
<br />16a. EMBALMER -SIGNATURE
<br />Matthew T. Myers
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths FuneraE Hanle, 2929 S. Locust Street, Grand Island, Nebraska
<br />Oa APT. NO.
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Leona Dismuke
<br />16b. LICENSE NO.
<br />1411
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />5 18. PART I. Enter the clrin of events- -diseases, injuries, or complicatlons4hat directly caused the death. DO NOT enter terminal events such as cardiac inset,
<br />respiratory meet, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEbiox c*igie(fkat a) Persistant Renal Insufficiency With Electrol ite Abnormality
<br />diaag dreondlicntssukktp
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially Het condition., N b)Diffuse Vascular Disease, Alzheimers Dementia With Diminished Oral Intake
<br />if fy, Msdine taebs cause Wed>
<br />online a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the untvERLY1NA Wogs :: c)
<br />Wigan or Injury that Initiated \
<br />the events resulting In death)
<br />LAST
<br />Sri* PART ll. OTHI»I
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />CI)
<br />9g, iNSlt cfRr Won
<br />arts ❑
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />16c. DATE (1,10.ilpityiEy.0
<br />February 210, 2012
<br />$:ATE
<br />Nebraska
<br />17t1 2;ip ti
<br />666Q'4,
<br />APPROXIMATE INTERVAL
<br />onset tod1$tE1 .'
<br />1 Week
<br />onset to death
<br />3 Months
<br />onset to dlitdtt>
<br />GNWF[CANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART 1.
<br />onset to deatit
<br />19. WAS MEDICAL;EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />2ti IF FEMALE
<br />. ,❑ Net pre9Pent Otto n past year <.
<br />❑ Pregnantatdm.atdsah
<br />0 Not pregnant, but preemie within 42 days of death
<br />0 Not pregnant, but pregnant 42 days to 1 year before death
<br />:1.:,. unknewn X pry flans rfNn die past year
<br />22aDATE OEINJURY (Mo.,;P�iy, Yr.)
<br />I
<br />1 22d. INJURY AT WORK?
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident 0 Pending Investigation
<br />❑ Bulc&de 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED? '!
<br />❑YES NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />g 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE
<br />>ZIpCOb� .
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 15, 2012
<br />•tad. DATE SIGNED(Mo., Day, Yr.) 23c. TIME OF DEATH
<br />1+ekZruaN 15f 2012 04:20 AM
<br />23d 7o snt bast of my lalois edge, death occurred at the time, date and place
<br />and'ds.to tl»:bause(s) stated. (Signature and rico
<br />Richard Fruehling, MD
<br />26. DID TOBACcO>USECQf$TRIBUTE TO THE DEATH?
<br />[YES „MUSIC ®No•❑PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD._#
<br />241. On the basis of examination and/or investigation, in my opinion death DOSS d at
<br />camels)the time, date and place and due to the camels) stated. (Signature and TM)
<br />28a. HAS ORGAN OR DONATION BEEN CONSIDERED?
<br />❑ YES R
<br />27. NA'
<br />ACID ADDRESS OF CERTIFIER (Type or Print
<br />Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island,_ • raska, 68803
<br />28a. REGISTRAR'S SIGNATUREMo /(- /M _
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO ❑ YES: ❑ NO i
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr4
<br />February 16, 2012
<br />
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