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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE 200200287 <br />NOV 3 0 20011 ANLEYS. COOPER <br />�7e� U _ - _ _ ASSISTANT STATE REGISTRAR <br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM <br />EXHIBIT <br />non <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT. 13104 <br />VITAL STATISTICS (L J1 <br />CF.RTTFTC.ATF n>~ nRATN <br />1. DECEDENT • NAME FIRST MIDDLE LAST <br />2. SEX <br />3. DATE OF DEATH lhlonin. Day. Yearl <br />Paula Jean Alms <br />Female <br />November 21, 2001 <br />i. CITY AND STATE OF BIRTH !I /npt in U.S.A.. name country) <br />5a. AGE -Last Birthday UNDER 1 YEAR <br />OER t OAY <br />6. DATE OF BIRTH /Monty. Day. Yea) <br />Newman Grove, Nebraska <br />(Yrs.l ib. MOS. GAYS <br />64 1 <br />RS' MINS. <br />f <br />October 18, 1937 <br />7. SOCIAL SECURTIY NUMBER <br />8a. PUS CE OF DEATH <br />505 -42 -3459 <br />HOSPITAL: ❑ Inpatient OTHER ❑ Nursing Home <br />® ER Outpatient ❑ Residence <br />Bb. FACILITY _ Name / //not institution. give street and number/ <br />York General Hospital <br />❑ ODA ❑ Other(Speclyr <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />8d. INSIDE is -Y LIMITS <br />Be. COUNTY OF DEATH <br />York <br />Yes E. NO ❑ <br />York <br />9a. RESIDENCE - STATE <br />9b. COUNTY <br />9c. CITY. TOWN OR LOC 11ON <br />9d. STREET AND NUMBER !Including Zip Code/ <br />9e. INSIDE CITY LIMITS <br />Nebraska <br />York <br />York <br />2028 Nebraska Av 68467 <br />Yes E No ❑ <br />10. RACE - (e.g., White. Black. American Indian. <br />I L ANCESTRY le.g.. Italian. Mexican. German. eicl Z ® MARRIED Q WIOOWED <br />13 NAME OF SPOUSE 0,0r. gne maiden name) <br />e1c.) ISoectfyl <br />White <br />(Specify) NEVER <br />Swede DIVORCED MARRI <br />LaVerne N. Alms <br />I4a. USUALOCCUPATION iGwe kind of work done during most tdb. <br />KIND OF BUSINESS INOL :CRY <br />15. EDUCATION (Specify only nighesl grade completed) <br />of working file. even dreeredl <br />Teacher <br />Public Sc:lools <br />Elementary or Secondary 10.121 Con e n .4 or 5 -t <br />4T <br />16. FATHER -NAME FIRST MIDDLE LAST <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Duvald Lundquist <br />Pauline Peterson <br />18. WAS DECEASED <br />EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT ;AME <br />(VCs. no. or unk.) <br />[if yes. give war and dates of servicesl <br />No <br />I <br />LaVerna: N. Alms <br />19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. S- E. ZIP( <br />202 ebraska Ave., York, NE 68467 <br />20. EM LME - SIGNATU d EN "11 <br />21a. METHOD OF DISPOSIT ': <br />21b. DATE CEMETERY OR CREMATORY. NAME <br />- / T 925 <br />aBunal P-­-, <br />121c. <br />Nov. 26, 2001 Greenwood Cemetery <br />22a. FUNERAL HOME -NAME <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Metz Mortuary, Inc. <br />❑Cremation ❑Dpr.:<., <br />York NE <br />221d. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br />109 So. Lincoln Ave. York Nebraska 68467 <br />21 PART IMMEDIATE CAUSE IENTER ONLY ONE CAUSE PER UNE FOR 1.1, IEI- AND c" I Interval between onset and detain <br />lal <br />I Interval between onset and deam <br />DUE TO, OR AS A CONSEOUEN E OF:('`' <br />` r/ `/ <br />LA <br />I <br />DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and deam <br />Icl I <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not r lLatetl PART <br />PART <br />III IF FEMALE WAS THERE A 24. <br />AUTOPSY <br />25, WAS CASE REFERRED TO MEDICAL <br />1 PREGNANCY <br />I �� +k-L- <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER? <br />get. Ytz v�� <br />�Age510.541 <br />Yes No <br />Yes No X <br />Yes No X <br />26a. <br />26b. DATE OF INJURY (Ma. Day. Yr.) <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />Accident � Undetermined <br />C <br />V <br />Suicide Pending <br />M <br />26e. INJURY AT WORK <br />I 2 6f. PLACE OF, INJURY - At home, )arm, seee. lactory <br />26g. LOCATION STREET OR R.FD. N0. CITY OR TOWN STATE <br />Homicide Investigation <br />❑❑ <br />of ice budding. etc. I pecdyl ^� <br />`•.J <br />�V\ <br />Yes Na <br />27a. DATE OF DEATH (hfa.. Day. Yr.) <br />28a. DATE SIGNED iMo_ Day. Yr1 <br />28b. TIME OF DEATH <br />a <br />November 21, 2001 <br />1- ' <br />M <br />ys <br />.r1- <br />9 <br />27b. DATE SIGNED (Ado. Day. Yr.) <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD (Mo.. Day, Yr) <br />28d PRONOUNCED DEAD (Hour) <br />� <br />$ <br />November -T3 2001 <br />9:42 A M <br />3� <br />�- - <br />- M <br />27d. To the best of my knowliggle. death occurred at tha t e, dale atld place and due to the <br />28e. On the basis of examination antlror investigation, in my opinion death occurred at <br />.2 $°• 0 <br />a <br />causelsl stated. <br />ci <br />the lime. date and place and due to the Causes stated. <br />M <br />(Si nature and Title) ► <br />IS' nature and Title) No <br />29. DID TOBaC SE CONTRIBUTE TO THE DEATH? 3Qa <br />HAS dRGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b <br />WAS CONSENT GRANTED' <br />YES NO ❑ UNKNOWN <br />❑ YES NO <br />YES N0 <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI !Type or Print) <br />David F. Demuth, MD York Medica Clinic 21 1 Lincoln York, NE 68467 <br />32a. REGISTRAR <br />• I&J <br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr1 <br />NOV 2 8 2001 <br />