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WFIEN MM COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTHAIIV0*ffAX iMWM- SYSTEA4 IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON -FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST1C_S3ECTl_ GW,*W1CH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE -^�`O �1 ANLEY S. COOPISR -: 9/8/2003 200408290 ASSISTANT $MTf Tq@TRhRi LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTI _ STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES F�,If -Si}�_.�(O'�RT CF.RTTFTCATE OF DEATH =- U 09885 I . DECEDENT - NAME FIRST MIDDLE LAST 2. SEX � `3. DATE OF DEATH /Month. Day Year) Janelle Victoria Rimbrough Female August 28, 2003 4. CITY AND STATE OF BIRTH /If not in U.S.A.. name country/ 5a. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (Monts. Day Year) MOS, DAYS Sc. HOURS MIN, )Yrs.l Sb. Grand Island, Nebraska 47 October 22, 1955 7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH HOSPITAL: ❑ Inpatient OTHER_. ❑ Nursing Home 507 -80 -9115 ❑ ER Outpatient FRI Residence 8b. FACILITY -Name (fl nol mstituban, give street and number) 7800 N. U.S. Hwy. 281 ❑ DOA ❑ Other fspecttvr 8c. CITY. TOWN OR LOCATION OF DEATH 8d, INSIDE CITY LIMITS Be COUNTY OF DEATH Grand I s laTnd Yes ❑ No [K Hall 9a. RESIDENCE -STATE 90 . COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER (Including Zp Code) 9e. INSIDE CITY LIMITS Nebraska Hall Grand Island 7800 N. U.S. Hwy 281 68803 Yes ❑ No 10. RACE - (e.g., White. Black, American Indian 11. ANCESTRY le.q.. Italian. Mexican, German, etcl 12. F MARRIED ❑ WIDOWED 13. NAME OF SPOUSE (If wile give maiden name) etc.( (Specify) (Specify) 1 NEVER DIVORCED Dr. James Rimbrough White American MARRIED 14a. USUAL OCCUPATION (Give kindof work done during most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) Elementary or Secondary 1012) College 11 -4 or 5-i of working life, even it retired( Sales Clerk Retail 12 16. FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Leslie B. Knudsen Dolores J. Jehorek 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME Y . no. or unk.) IIf yes. give war and dates of services) No Dr. James Kimbrough 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP) 7800 N. U,S. Hwy 281, ,Grand Island, Nebraska 68803 _ 20. MER -SIGN U E LICENSE N 21 a. METHOD OF DISPOSITION 21b. DATE 27 C. CEMETERY OR CREMATORY NAME G #1071 ❑X Burial ❑ Removal S�e:[�7 202003 Grand Island City Cemetery 2 ERAL H E - 17AME , 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE All Faiths Funeral Home ❑ Cremation ❑ Donation Grand Island, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP) 2929 S. Locust St., Grand Island, Nebraska 68801 23. IMMEDIATE CAUS (ENTER ONLY O E CAUSE PER LINE FOR (a) . (b). AND (c)( I Interval between onset and dealt, PART 2 a ��NT R O a� a sr C�4,vcc 1 ut oV1� al v DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death IL I DUE TO. OR AS A CONSEQUENCE OF Interval between onset ono dean q OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER' I (Ages 10 -54) Yes D No a Ves No Yes No 26a. 26b. DATE OF INJURY (Md. Day. Yr.) 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident Undetermined pt ❑ Suicide D Pending 26e. INJURY AT WORK 26f. office E OF Stehc me, farm. street. factory 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide InvesLgaLon Yes ❑ No ❑ building, P tYl 27a. DATE OF DEATH (Mo.. Day. Yr.) 28a. DATE SIGNED (Mo.. Day. Yr) 28b TIME OF DEATH August 28, 2003 <w oN� M �a v " °�-' >- 27b. DATE SIGNED (Ma. Day Yr.l 27c TIME OF DEATH 28c. PRONOUNCED DEAD iMo.. Day, Yr) 28d. PRONOUNCED DEAD (Hour 41 _o 'Do' � 5:21 P.M °wz° ° M 27d To the best of my knowledge death occurred at the time, date and place and due to the 28e. On the basis of examination and or Investigation, In my opinion death occurred at ¢ ° a cause(sl stated. the time. date and place and due to the cause(s) stated. (Signature and Title) ► > ISi nature and Title( ► 29. DID TOBACCO USE CONTRIBUTE TO THE DrUNKNOWN O.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED' ❑ YES NO El YES NO ❑ YES NO 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) 17ypeor Print) Richard Fruehling M.D., 2116 W. Faidle e., Suite 400, Grand Island, NE 68803 32a. REGISTRAR - 32b. DATE FILED BY REGISTRAR (Mo., Day Yr) S E P 4 2003