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STATE OF NEBRASKA
<br />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 RECf)R5011if,L ILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI$ #CS_SEGTM-
<br />W-*lICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _- --
<br />DATE OF ISSUANCE -
<br />MAY ii 3 Zqq`? ASSISTANT STATE RitCISTRAR
<br />LINCOLN, NEBRASKA HEALTH =AND HUMAN SSERVEES
<br />200504550 _-
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT 0 5 O Q 5
<br />CERTIFICATE OF DEATH _ 4VJ...
<br />[Beverly DECEDENTS-NAME (First, Middle, Last, Suffix) 2. SEX - 3. DATE OF DEATH (Mo.. Yr.)
<br />Bessie Oletha Everson Female April 26, 2005
<br />ITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE•Last Birthday 55c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs.) 88 MOS. DAYS HOURS MINS. i,ly 18, 1916 Minatare, Nebraska OCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />506 -22- 5585_ HOSPITAL: ❑ Inpatient QT}1EB: M Nursing Home /LTC ❑ Hospice Facility
<br />FACILITY -NAME (II not institution, give street and number) ❑ ER /Oulpatien! ❑Decedent's Home
<br />Healthcare Park Place ❑ D, ❑ Other (Specify)
<br />Be, CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE,STATE 9b. COUNTY
<br />Nebraska Hall
<br />9d ST RE ET AND NUMBER
<br />610 N. Darr
<br />toa. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married
<br />❑ Married, but separated del Widowed ❑ Divorced ❑ Unknown
<br />d, COUNTY OF DEATH -
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island -
<br />9e. APT. NO 9f. ZIP CODE
<br />68803
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Donald I. Everson (Dec)
<br />9g. INSIDE CITY LIMITS
<br />IA YES ❑ NO
<br />- _..._- Maiden Surname
<br />Suffix) 12. MOTHER'S-NAME (First, Middle,
<br />11. FATHER'S -NAME (First, Middle, Last, )
<br />Ephram A. Baker Gertrude A. Weston
<br />_.
<br />13. EVER IN U.S. ARMED FORCES? Give dates of servica if yes. 14a, INFORMANT -NAME 166. RELATIONSHIP T,p DECEDENT
<br />Darrel Watson son
<br />(Yes, rlo, or unk.) No -.--.---,.-son
<br />.- '- -'
<br />15. METHOD OF DISPOSITION 16a. EMBALMER SIGNATURE 16o. LICENSE NO. 160. DATE (Mo., Day, Yr. )
<br />M Burial ❑Donation c.�c�..�.., L:.� .4.ti..d�.�fi ". 1143 April 30, 2005
<br />El Cremation C3 Entombment
<br />16d, CEMETERY. CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br />U Removal ❑ Other (Specify) Westlawn Memorial Park Cemetery, Grand Island, Nebraska
<br />176.
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) ,Zip Code
<br />Livingston- Sondermann Funeral Home, 601 N. Webb Road, Grand Island, NE 68803
<br />18 PART I. Enter the chain-of events •Alseasos, injuries, or complloatlons- -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />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
<br />underlying .. ..-
<br />18, PART IL OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the under) in cause given in PART I. 19. WAS MEDICAL EXAMINER
<br />i1% ( �vl�Ctl �n t�i�7l >- ORCORONERCONTACTED7
<br />X
<br />r���r N_ � ►� No(%O, A-j fkz istr A GcRo /�.)(3� -rru4 C r -� �� r3 U YES °NO _
<br />20. IF FEMALE: 21a. MANNEROF DEATH 21b.IFTRANSPORTATIONINJURY F ASANAUTOPSYPERFORMED?
<br />X �.(Valural ❑ Homicide U Drivar /Operator
<br />�,Not pregnant within past year C3 YES �NO
<br />C3 Passenger
<br />• Pregnant at time of death ❑ Accldenl❑ Pending Investigation
<br />QPedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />• Not pregnant, but pregnant within 42 days of death ❑ Sulclde ❑ Could not be determined LJ Other (Specify)
<br />COMPLETE CAUSE OF DEATH?
<br />• Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ YES Cl NO
<br />❑ Unknown if pregnant within the past year - - -
<br />_ 223. DATE OF INJURY (Mo.. Day, Yr.) 22b, TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction alto, etc. (Specify)
<br />22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />C3 YES C: NO �._...
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CRY/TOWN
<br />STATE ZIPCODE
<br />- 24b.TIMEOFDEATH
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />a April 26, 2005 r, an
<br />_ _..
<br />_..
<br />V = 24c. PRONOUNCED DEAD (Mc., bay, Yr.) 24d. TIME PRONOUNCED DEAD
<br />23 TESIGNED(Mo.,Day,Yr.) 23o.TIMEOF.DEATH
<br />Ear -b- �_ -� 08:15 am E0 z rn
<br />E :� z
<br />E c 23d-To the best of my knowledge, death occurred at the time, date and place $ _ O 24e. On the basis of examination and /or Investigation, in my opinion death occurred at
<br />n and due to the causes) staled. (Signature and Title) V c ¢ V the time, dale and place and due to the cause(s) stated. (Signature and Title)
<br />0
<br />X t
<br />~ Q ( v o
<br />Q, ..1 kj
<br />25. DID TOBACCO USEC THIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREO? 26 b. WAS CONSENT GRANTED? ��
<br />,�- A L}r `/ Not Applicable It 26a is NO [J YES 2.110
<br />El YES 0 C3 PROBABLY ❑ UNKNOWN ❑ YES 0 -
<br />_.
<br />27. NAME, TITLE AND AOpHF5S..0E_GEH FIl IER (PHYSICIAN, CORONER'S PHYSICIAN 0 OUNT ATTORNEY) (T
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />28a. REGISTRAR'S SIGNATURE APR 2 8 2005
<br />IMMEDIATE CAUSE:
<br />onset to death
<br />S�L�cuY,(:L..s C�tin�- Vtal�
<br />IMMEDIATE CAUSE (Final
<br />(a) cell _
<br />_
<br />onset to death
<br />disease or condition resulting
<br />DUE TO, OR ASA CONSEQUENCE OF!
<br />In death)
<br />I
<br />Sequentially list conditions, If
<br />-DUE
<br />(b) _
<br />_ .
<br />onset to death
<br />any, leading to the cause listed
<br />TO, OR AS A CONSEQUENCE OF:
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that Initiated
<br />(o)
<br />P onset todeath
<br />the events resulting lndeath)
<br />DUE 70, OR AS A CONSEQUENCE OF:
<br />LAST
<br />I
<br />underlying .. ..-
<br />18, PART IL OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the under) in cause given in PART I. 19. WAS MEDICAL EXAMINER
<br />i1% ( �vl�Ctl �n t�i�7l >- ORCORONERCONTACTED7
<br />X
<br />r���r N_ � ►� No(%O, A-j fkz istr A GcRo /�.)(3� -rru4 C r -� �� r3 U YES °NO _
<br />20. IF FEMALE: 21a. MANNEROF DEATH 21b.IFTRANSPORTATIONINJURY F ASANAUTOPSYPERFORMED?
<br />X �.(Valural ❑ Homicide U Drivar /Operator
<br />�,Not pregnant within past year C3 YES �NO
<br />C3 Passenger
<br />• Pregnant at time of death ❑ Accldenl❑ Pending Investigation
<br />QPedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />• Not pregnant, but pregnant within 42 days of death ❑ Sulclde ❑ Could not be determined LJ Other (Specify)
<br />COMPLETE CAUSE OF DEATH?
<br />• Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ YES Cl NO
<br />❑ Unknown if pregnant within the past year - - -
<br />_ 223. DATE OF INJURY (Mo.. Day, Yr.) 22b, TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction alto, etc. (Specify)
<br />22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />C3 YES C: NO �._...
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CRY/TOWN
<br />STATE ZIPCODE
<br />- 24b.TIMEOFDEATH
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />a April 26, 2005 r, an
<br />_ _..
<br />_..
<br />V = 24c. PRONOUNCED DEAD (Mc., bay, Yr.) 24d. TIME PRONOUNCED DEAD
<br />23 TESIGNED(Mo.,Day,Yr.) 23o.TIMEOF.DEATH
<br />Ear -b- �_ -� 08:15 am E0 z rn
<br />E :� z
<br />E c 23d-To the best of my knowledge, death occurred at the time, date and place $ _ O 24e. On the basis of examination and /or Investigation, in my opinion death occurred at
<br />n and due to the causes) staled. (Signature and Title) V c ¢ V the time, dale and place and due to the cause(s) stated. (Signature and Title)
<br />0
<br />X t
<br />~ Q ( v o
<br />Q, ..1 kj
<br />25. DID TOBACCO USEC THIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREO? 26 b. WAS CONSENT GRANTED? ��
<br />,�- A L}r `/ Not Applicable It 26a is NO [J YES 2.110
<br />El YES 0 C3 PROBABLY ❑ UNKNOWN ❑ YES 0 -
<br />_.
<br />27. NAME, TITLE AND AOpHF5S..0E_GEH FIl IER (PHYSICIAN, CORONER'S PHYSICIAN 0 OUNT ATTORNEY) (T
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />28a. REGISTRAR'S SIGNATURE APR 2 8 2005
<br />
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