|
lost. 2004 - 1926
<br />WHEN THIS COPY CARRAES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTE14 R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTCC IISM *%VCH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />4�: �:, ; ANLEYS.�0011€
<br />6/23/2003 200402281 ASSUTANT# __
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERWCES'SYSMU
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMANAkkhCgS;A� AT�UPPORT
<br />VITAL STATISTCS -+- ' - - O 3 0
<br />CERTIFICATE OF DEATIE -r -- VV
<br />NJ
<br />6965
<br />1. DECEDENT NAME FIRST
<br />MIDDLE LAST
<br />24. AUTOPSY
<br />2. SEX- ' - =_
<br />DATE OF DEATH (Month, Day, Year)
<br />Reva L. Headley
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />13.
<br />Female
<br />June 11, 2003
<br />4. CITY AND STATE OF BIRTH (M not in U.S.A., name country)
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH (Month, Day, Year)
<br />Sb. MOS.
<br />DAYS
<br />5c. HOURS MINS-
<br />Rural Gibbon NE
<br />(Yrs.) 87
<br />December 19, 1915
<br />7. SOCIAL SECURITY NUMBER
<br />M
<br />8a. PLACE OF DEATH
<br />505 -56 -6056
<br />26e. INJURY AT WORK
<br />HOSPITAL:
<br />❑ Inpatient OTHER: ❑ Nursing Home
<br />❑ Homicide Investigation
<br />Yes El No
<br />office etc. (Specify)
<br />❑ER Outpatient ® Residence
<br />8b. FACILITY - Name (ifnot institution, give street and number)
<br />5262 S. Bluff Center Rd
<br />27a. DATE OF DEATH (Mo.. Day, Yr.)
<br />❑ DOA ❑ Other (Specify)
<br />8c. CITY, TOWN OR LOCATION OF DEATH
<br />28b. TIME OF DEATH
<br />8d, INSIDE CITY LIMITS 8e.
<br />COUNTY OF DEATH
<br />Shelton
<br />Yes ❑ No 0
<br />I
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />27b. DATE SIGNED (Mo., Day, Vr I 27a T;ME OF DEATH
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including Zip Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />I
<br />.8
<br />Shelton
<br />5262 S. Bluff Center Rd
<br />I Yes ❑ No 0
<br />10. RACE - (e.g., White, Black, American Indian,
<br />(e.g., Ralian, Mexican, German, etc.)
<br />WIDOWED
<br />[:]MARRIED 21
<br />NAME OF SPOUSE (if wile, give maiden name)
<br />etc.) (Specify)
<br />(Specify)
<br />b
<br />the time, dale and place and due to the cause(s) stated.
<br />Si aUS and Title
<br />White
<br />111.ANCESTRY
<br />American
<br />112* 113.
<br />NEVER DIVORCED
<br />❑ ❑
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />MARRIED
<br />❑ YES NO ❑ UNKNOWN
<br />❑ YES R�INO
<br />14a. USUAL OCCUPATION (Give kind of work done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />115.EDUCATION
<br />SPECIFY ONLY HIGHEST GRADE COMPLETED
<br />of working life, even if retired)
<br />Teacher
<br />Education
<br />Elementary or Secondary (0.12) College (1.4 or 5 +)
<br />5+
<br />16. FATHER - NAME FIRST MIDDLE
<br />LAST 17.
<br />MOTHER
<br />FIRST MIDDLE LAST
<br />William E.
<br />Gamble I
<br />Zora Mae Randall
<br />18. WAS DECEASED EVER
<br />IN U.S. ARMED FORCES?
<br />IW. INFORMANT- NAME
<br />!• yas, .^i':a ..:, c-. - ,.. scrviceW
<br />No
<br />I
<br />Sandra Headley
<br />20744 Yewwood Lane, Alsea , OR 97324
<br />20. L - SIGNATURE ENS NO. �-7r 21a. METHOD OF DISPOSITION 21b. DATE 21 c. CEMETERY OR CREMATORY -NAME
<br />llyf 9`6' � 0 Burial ❑ Removal June 16, 2003 1 Riverside Cemetery
<br />2247FUKERAL HOME - E 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Godberson ortuary ❑ Cremation ❑ Donation Gibbon NE
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />719 Front St. P.O. Box 10, Gibbon, NE 68840
<br />23. IMMEDIATE CAUSE }/ (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c) Interval between onset and death
<br />PART t 1
<br />(a a) . r. CG r G I F
<br />DUE TO OR AS A CONSEQUENCE OF Interval between onset and death
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contdbuing to the death but not related
<br />PART III IF FEMALE WAS THERE A
<br />24. AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />PART
<br />It
<br />(Ages 1454) Yes [] No �/
<br />Yes [] No ®
<br />Yes ® No ❑
<br />26a.
<br />26b. DATE OF INJURY (Mo., Day, Yr)
<br />26c. HOUR OF INJURY
<br />28d. DESCRIBE HOW INJURY OCCURRED
<br />❑ Accident ❑ Undetermined
<br />M
<br />❑ Suicide ❑ Pending
<br />26e. INJURY AT WORK
<br />126f. PLACE OF INJURY- At home, farm, street, factory
<br />building,
<br />26g. LOCATION STREET OR R.F.D NO. CITY OR TOWN STATE
<br />❑ Homicide Investigation
<br />Yes El No
<br />office etc. (Specify)
<br />27a. DATE OF DEATH (Mo.. Day, Yr.)
<br />28a. DATE SIGNED (Mo., Day, Yr.)
<br />28b. TIME OF DEATH
<br />June 11, 2003
<br />t,-,IJ � %3
<br />- Y -119 -M
<br />8v
<br />;
<br />ro T
<br />27b. DATE SIGNED (Mo., Day, Vr I 27a T;ME OF DEATH
<br />28c. PKCiNOUNCED UtAw (Mo., way, rc/
<br />28d. PRONOUNCED DEAL) (Hour;
<br />=
<br />12:45 A. M
<br />.8
<br />� - //-.9m
<br />�% 3 � M
<br />gb
<br />12 b
<br />F
<br />27d. To the best of my knowledge, death occurred at the time,dale and place and due to the
<br />28e. On the basis o1 etcanwns8on pndlor investigation, in my opinion death occurred at
<br />/-
<br />cause(s) stated.
<br />b
<br />the time, dale and place and due to the cause(s) stated.
<br />Si aUS and Title
<br />Si ature and Title
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30b. WAS CONS GRANTED?
<br />❑ YES NO ❑ UNKNOWN
<br />❑ YES R�INO
<br />❑ YES K�AC
<br />Jl. NMMCANUAUUKtJJ Ur UCK I IritK (FHYSIUUW, UUKUNtKS YKYSIUTAN UK UUUNIY AI IUKNtYd (type or YOM)
<br />Quinn Webb,Dpty Co. oroner . 131 Locust, Grand Island, NE 68801
<br />32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo., Day, Yr..)
<br />JUN 2 0 2003
<br />
|