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20260403
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENTOF
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITOR'
<br />DATE OF ISSUANCE
<br />11/23/2015
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND
<br />CERTIFICATE OF DEATI
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Raylene Sandra Simon
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />O'Neill, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508-68-1572
<br />8b. FACILITY -NAME Of not Institution, give street and number)
<br />Memorial Hospital -Aurora
<br />ee, CITY OR TOWN OF DEATH (include Zip Code)
<br />Aurora 68818
<br />. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />u.
<br />h
<br />2309 West Blake St.
<br />Bb. COUNTS'
<br />Hall
<br />10.. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Mauled
<br />0 Mauled, but separated ❑ Widowed 0 Divorced 0 Unl(no*tl
<br />11. FATHER'S -NAME (First, Middle, Last, Swmx)
<br />Raymond Ray Nemec
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service NY**.
<br />(Yes, No, or Unit.) NO
<br />15. METHOD OF DISPOSITION
<br />Q BUNS! ❑ Donation
<br />Cremation 0 Entombment
<br />�] Removal 0 Other(Specify)
<br />5b. UNDER't
<br />MOS DA
<br />8a. PLACE OF DEATH
<br />MINIM. 0 Inpatient
<br />Eft/Outpatient
<br />a Loa
<br />9c. CITY OR TOWN
<br />Grand Island
<br />0 geppitimt's Mrs.
<br />Ost.r(specKy)
<br />8d. BOUNTY OF DEATH
<br />Hamilton
<br />SS. APT.' NO.
<br />10b. NAME OP SPOUSE (First, MIddt►, Last,
<br />George Wiliam Simon
<br />12. MOTHER'S NAME (First, ! MWsiai _li(iddart Slfrnarlt.),:....
<br />Naomi Froseth..
<br />14a, INFORMANT -NAME
<br />George William Simon
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />9f. MP ODD
<br />t$803
<br />Ted. CEMETERY, CREMATORY OR OTHER LOCATION,
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City Or Town, Mate)
<br />Alt Faiths Funeral Home, 2929 S. Locust Street,,Grand Island, Nebraska'
<br />UCENSB NO::
<br />aureate we., ova. tt
<br />GI►bbon;
<br />CAUSE o0 DEATA tsee Inslifuetioif$"aed 4xaa4lN
<br />to PART I. II r the ;kiln of avente ems. Injuries, orcempllcNMns4f at dlrectlpcaused 19111 rMepl. pO NOT sitter twnrNylFsfnlr gush droatp(es
<br />respiratory arrest, or ventricular flbrNlition without showing the.Eol.gy, CO NOT A08REVIATE. Enter enyefi Souse eel a inno Adl
<br />MMtEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In death)
<br />SequenflaNylist condlSons,N
<br />any, leading to pat souse Sated
<br />en Nero a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that Initiated
<br />the events resulting In death)
<br />LAST
<br />IMMEDIATE CAUSE:
<br />a)V Fib
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A 4ONSEQUENCE OP:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d).
<br />15. PART 11. OTHER SIGNIFICANT CONDITIONS.Condidons contributing to the death
<br />Diabetes, Rheumatoid Arthritis
<br />IF FEMALE:
<br />® Not pregnant within past year
<br />0 Pregnant at time or deem
<br />Not pregMnt, but pregnant within 42 days of death
<br />O Not pregnant, but pregnant 43 days tot year before. death
<br />El Unknown N pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />2d. INJURY AT WORK?
<br />OYES O NO
<br />21a: MANNER OF DEATH
<br />Natural 0 Homkid.
<br />Aced.* 0 Pending:lnvertlgation
<br />13 Suicid. r3Could not be daemons';
<br />not resulting in the d1daftlilhl cal $s siren M PARTS.
<br />22b. TIME OF INJURY
<br />21b. IF TRIINSPORTAT1ON° INJURY IC4 WAS
<br />tMINIrtOpweter
<br />0 Pasadg.r �.. Vfi81. -....
<br />El P4deam.a 21d WE Ru r
<br />0 Other (sp•cWtYF
<br />onna nr1TiMi
<br />TES.`'.. }; NQ
<br />•
<br />R AT I P 0,
<br />1
<br />mho
<br />wA'
<br />YES , `t:1MO
<br />22c. PLACE OF INJURY -At hone, farm, street, factory, dffh:e buIIdIng, dohsNus5dt►-
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DAT@ OF DEATH (MO., Day, Yr.)
<br />November 13, 2015
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />November 16 2015
<br />i2TYrTOWN
<br />23c. TIME OF DEATH
<br />07:56 PM
<br />• . To the best of my knowledge, death oscuned at the time, dot• and place
<br />and due to the cousins) stated. (Signature and This)
<br />Jeff Muilenburg, MD
<br />ATE
<br />24w On the bens of .xaminaddn an4hr leveapglin, In,
<br />the time, date and pied hid des tOlferqusets) "
<br />2$. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 1213a. HAS ORGAN OR T
<br />t
<br />YES 0 NO 0 PRO$ABLY UNKNOWN ®
<br />,��IIYES
<br />7. RAME, TILE AND ADDRESS OF CERTIPWR (Tyro of Prin
<br />Jeff Muilenburg, MD, 609 0 Street, Aurora, Nebraska, 68818
<br />r . . REGISTRAR'S SIGNATURE
<br />DONATION BEEN CONS
<br />❑NO
<br />2eb WASCONIMWIt 0
<br />Not Applicable R 21411a NO
<br />28t1. DATE PILED BY REGIS -11
<br />November 18, 2015
<br />)
<br />'' Il
<br />
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