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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL_REi CM-0N FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI1$tCS--0,&CVC ,,=WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE MAR ZOU� ) TANLEY S. COOPER LINCOLN, NEBRASKA 2005007 2 5 HEALTH AND HUMAN 9ERWCES STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SF7PP T CERTIFICATE OF DEATH 05 -0-1Zn 1. DECEDENT'S•NAME (First, Middle, Last, Suffix) 2. SEX 3, DATE OF DEATH (Mo., Day, Yr.) Ruth Marie Everett Female February 6, 2005 4, CITY AND STATE OR TERRITO FOR .._.._....... __.- __...._..,....._.....____ RY, OR FOREIGN COUNTRY OF BIRTH Se. AGE-Last Birthday 5b. UNpER 1 YEAR 5c. UNDER 1 DAY 6, DATE OF BIRTH (Mo., Day, Yr.) (Yrs.) MOS. DAYS HOURS MINS. Council Bluffs, Iowa 75 October 22, 1929 7. SOCIAL SECURITY NUMBER Bs. PLACE OF DEATH 482 -26 -7786 HOSPITAL: ❑ Inpatient QUHE%: �NursingHome /LTC L1HocpiceFacility Ob. FACILITV,NAME� (II not institution, glue street and number) ❑ ERlOutpetlent ❑Decedent's Home Park Place Nursing Home I ❑ D04 ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) ed. COUNTY OF DEATH Grand Island, Nebraska 68803 Hall 9a. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN Nebraska _ _ Hall Grand Island 9d. STREET AND NUMBER 9e. APT. NO. 9f. ZIP CODE 9g. INSIDE CITY LIMITS 3027 West Capital y 4k 1;4 68803 )7 YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH C! Married U Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. U Married, but separated ❑ Widowed Cl Divorced U Unknown Jay C. Everett 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname) Lloyd Crawford Collins Josephine -Julia Peterson 13. EVER IN U.S. ARMED FORCES? Give dates of service It yes. 14a. INFORMANT -NAME 14b. RELATIONSHIP TO DECEDENT (Yes,no,orunk.)Yes Oct.20,1948-Aug_._,.29, 1951 Jay C. Everett Husband 15. METHOD OF DISPOSITION 16a. EMBALMER•SIGNATURE i6b. LICENSE NO. 23b. DATE SIGNED Day�('y�.) 16c. DATE (Mo., Day, Yr.) U Burial El Donation Not Embalmed 24d. TIME PRONOUNCED DEAD E a t Feb. 7, 2005 la Crematlon ❑ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION W CITY/TOWN STATE ❑Removal ❑ Other (Specify) Westlawn Memorial Park Crematory Grand Island, Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town. State) 171b. Zip Code Livingston - Sondermann Funeral Home 601 N. Webb Rd. Grand Island, NE. 1 68803 18. PART I. Enter the chain of events - -diseases, injuries, or compllcatlons - -thal directly caused the death. 00 NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL I respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. I IMMEDIATECAUSE: onsettodeath I IMMEDIATE CAUSE (Final (a) disease orcondhlonresulting DUE TO, OR AS A CONSEQUENCE OF: i onset to death In death) Sequentially list conditions, If any, leading to the cause listed on line a. Enterthe UNDERLYING CAUSE (disease or Injury that Initiated the events resulting in death) LAST (b) DUE T0, OR AS A CONSEQUENCE OF: (c) DUE T0, OR AS A CONSEQUENCE OF: I I I onset to death I I I onset to death I loll I 18. PART 11. OTHER SIGNIFICANT CONDITIO _ NS- Condltlone canlribuling to the death but not resulting in the underlying cause given In PART I. 19, WAS MEDICAL EXAMINER OR CORONER CONTACTED? X ❑uYES - NO 21c. WAS AN AUTOPSY PERFORMED? v 11 YES NO ❑Accident❑ Cl Passenger Pending investigation /ti Q Suicide ❑Could not be determined Cl Pedestrian 21d .WEREAUTOPSY FINDINGS AVAILABLE TO <20, IF FEMALE: 0 Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death U Unknown If pregnant within the pest year vItr,M et G ... __. '.la. MANNER OFDEATH 211b.IFTRANSPORTATION Natural ❑ Homicide U Driver /Operator 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m ❑Other(Speclly) COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY ATWORK? 22e. DESCRIBE HOW INJURY OCCURRED - ❑ YES ❑ NO 221. LOCATION OF INJURY- STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE 25. DIDTOBACCOUSE CONTRIBUTE TO THE DEATH? HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 2 b.WASCONSENTGRANTED? U YES El ❑ UNKNOWN Cl YES `�LNO Not Applicable if 26a is NO U YES X NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER ( PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) 28a. REGISTRAR'S SIGNATURE 281b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) FEB - 0 2005 23a. DATE OF DEATH (Mo., Da , Yr.) Z r 24a. DATE SIGNED (Mo., Day, Yr,) 24b.TIME OF DEATH KLZ 23b. DATE SIGNED Day�('y�.) 23c.TIME OF DEATH _ 24c. PRONOUNCED DEAD (Mo., Day, Yr,) 24d. TIME PRONOUNCED DEAD E a t A(Mo., �. I n d •� %� '� rL m E H z fit `c' c O 0 w e 23d. To the best of my knowledge, death occurred at the lime, data and place z � ZO 2qe. On the basis of examination and/or investigation, in my opinion death occurred at �( the ca a to I ature and V /s /I \ /app /�dl7g \fit *+Title) 12 cc 0 25. DIDTOBACCOUSE CONTRIBUTE TO THE DEATH? HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 2 b.WASCONSENTGRANTED? U YES El ❑ UNKNOWN Cl YES `�LNO Not Applicable if 26a is NO U YES X NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER ( PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) 28a. REGISTRAR'S SIGNATURE 281b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) FEB - 0 2005