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I st. 2004 - 1927
<br />WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, !f CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD. DUI FILE WIT'j
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC4S -)"-,- H IV
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE t.
<br />2 2 8 N ANLEY S.
<br />.2� COOPED
<br />6/23/2003 ASSISFANTAME g,4v"IC
<br />LINCOLN, NEBRASKA HEALTH AND FRlMAN "SERVICI YST 11_
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEKOIC t-�CE SUPPORT
<br />VITAL STATISTCS --77-7- - ` ®� 06965
<br />CERTIFICATE OF DEATH -- - -
<br />0
<br />a�
<br />U
<br />A
<br />1. DECEDENT NAME FIRST
<br />MIDDLE LAST
<br />PART a)
<br />2. -SEX ? 3.
<br />DATE OF DEATH (Month, Day, Year)
<br />Reva L. Headley
<br />DUE TO OR AS A CONSEQUENCE OF -
<br />Female
<br />June 11, 2003
<br />4. CITY AND STATE OF BIRTH (if not in U.S.A., .name country)
<br />DUE TO OR AS A CONSEQUENCE OF
<br />5e. AGE - Last Birthday
<br />I UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH (Month, Day, Year)
<br />5b. NOS.
<br />DAYS
<br />5c. HOURS MINS.
<br />Rural Gibbon NE
<br />(Y-) 87
<br />December 19, 1915
<br />7. SOCIAL SECURITY NUMBER
<br />26f
<br />buOilF INJURY- A(S�� farm, street, factory
<br />Be. PLACE OF DEATH
<br />❑ Homicide Investigation
<br />505 -56 -6056
<br />office
<br />HOSPITAL:
<br />❑ Inpatient OTHER, ❑ Nursing Home
<br />DATE OF DEATH (Mo., Day. Yr.)
<br />28a. DATE SIGNED (Mo., Day, Yr.)
<br />❑ ER Outpatient ® Residence
<br />8b. FACILITY - Name (ifnot institution, give street and number)
<br />5262 S. Bluff Center Rd
<br />E/� %3
<br />❑ DOA ❑ Other (Specify)
<br />Be, CITY, TOWN OR LOCATION OF DEATH
<br />k }
<br />8d, INSIDE CITY LIMITS 8e.
<br />COUNTY OF DEATH
<br />Shelton
<br />28d. PRONOU LACED DEAD ('noun
<br />Yes El No .0
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />�y - //- 643
<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 />Shelton
<br />1 5262 S. Bluff Center Rd
<br />Yes ❑ No
<br />1
<br />10. RACE - (e.g., White, Black, American Indian,
<br />(Specify)
<br />11. ANCESTRY (e.g., Italian, Mexican, German, etc.)
<br />12. M MARRIED ® WIDOWED
<br />13. NAME OF SPOUSE (Mwife, give maiden name)
<br />etc.)
<br />White
<br />(Specify)
<br />American
<br />NEVER DIVORCED
<br />❑ ❑ 1
<br />❑ YES 0 NO ❑ UNKNOWN
<br />❑ YES FLI�NO
<br />❑ YES Pilo
<br />MARRIED
<br />14a. USUAL OCCUPATION JGive 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 (D-1 2) College (15 +5 +)
<br />16. FATHER - NAME FIRST MIDDLE
<br />LAST 17.MOTHER
<br />FIRST MIDDLE LAST
<br />William E.
<br />Gamble I
<br />Zora Mae Randall
<br />18. WAS DECEASED - EVER
<br />M U.S. ARMED FORCES?
<br />-
<br />19a. INFORMANT - NAME
<br />No
<br />yas, eivv •.:a: aa_ J. sc;viccc)
<br />Sandra Headley
<br />1 M0. I.,UK-I M9ILINU AUURCJJ (J I Rtt I UK R.Y.U.NU_, IIT UK I-N, JIAIC, LIP)
<br />20744 Yewwood Lane, Alsea , OR 97324
<br />- SIGNATURE EN NO. 21a. METHOD OF DISPOSITION 21b. DATE T1c- CEMETERY OR CREMATORY - NAME
<br />9SV 0 Burial ❑ Removal June 16, 2003 Riverside Cemetery
<br />22. RAL HOME - E 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Godberson 0 uary ❑Cremation ❑ Donation Gibbon NE
<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)
<br />Interval between onset and death
<br />PART a)
<br />25. WAS CASE REFERRED TO MEDICAL
<br />14r,
<br />IN THE PAST 3 MONTHS?
<br />DUE TO OR AS A CONSEQUENCE OF -
<br />Interval between onset and death
<br />PART
<br />II (Ages
<br />x (�/► 4 17 JW).,
<br />DUE TO OR AS A CONSEQUENCE OF
<br />Interval between onset and death
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contribuing to the death but not related PART
<br />III IF FEMALE WAS THERE A
<br />24. AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />PART
<br />II (Ages
<br />10-54) Yes ❑ No ®
<br />Yes ❑ No ®
<br />Yes ® No ❑
<br />28a.
<br />26b. DATE OF INJURY (Mo., Day, Yr.)
<br />28c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />❑ Accident ❑ Undetermined
<br />M
<br />❑ Suicide ❑ Pending
<br />26e. INJURY AT WORK
<br />26f
<br />buOilF INJURY- A(S�� farm, street, factory
<br />26g. LOCATION STREET OR R.F.D NO. CITY OR TOWN STATE
<br />❑ Homicide Investigation
<br />Yes ❑ No
<br />office
<br />DATE OF DEATH (Mo., Day. Yr.)
<br />28a. DATE SIGNED (Mo., Day, Yr.)
<br />28b. TIME OF DEATH
<br />[27a.
<br />June 11, 2003
<br />E/� %3
<br />: y$fj,M
<br />54
<br />v
<br />k }
<br />27b. DAFE SIGNED (Mo., Dev, vr)
<br />27c. 7;ME OF DEATH
<br />28c. PRONOUNCED UtIW IMo., way, &..)
<br />28d. PRONOU LACED DEAD ('noun
<br />Rp
<br />=
<br />12:45A. M
<br />N
<br />�y - //- 643
<br />�)3� M
<br />B1,
<br />48
<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 of examination and/or investigation, in my opinion death occurred at
<br />cause(s) stated.
<br />b
<br />the time, date and place and due to the cause(s) stated.
<br />Si lure and Title
<br />(Signature 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 0 NO ❑ UNKNOWN
<br />❑ YES FLI�NO
<br />❑ YES Pilo
<br />Jl. W It AriU AUUResJ UP UCR I WILK (PNTNU IAN, UURUNCR "J FHYSICIAN UK UUUN I Y A I I URNtY e hype dr rnm)
<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 />
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