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<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 RECORMON FILE AM11 H
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC4- "!C- 9
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. -
<br />DATE OF ISSUANCE
<br />AIIJL MS. �COOPEN
<br />NOV 19 2002 200507288 ASSISTANTSTilTEI SO&RAR. _-
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SYSrEAf
<br />r STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SFAM - - - _ - „ $HPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH T' 02 13141
<br />J
<br />1, DECEDENT • NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH (Monet. Day. Year)
<br />Christine Pauline Sears
<br />Female
<br />November 4, 2002
<br />4. CITY AND STATE OF BIRTH (argt in USA„ nacre p fty)
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER I DAY
<br />6. DATE OF BIRTH ~fli, Day, Year)
<br />(Yrs.I 56.
<br />MOS DAYS
<br />5c, HOURS 1 MIN'.
<br />Dallas South Dakota
<br />87 1
<br />1
<br />]November
<br />7. SOCIAL SECURTIV NUMBER
<br />.............
<br />Ba. PLACE OF DEATH
<br />505 -6$ -2758
<br />HOSPITAL: ❑ Inpatient OTHER' ® Nursinq Hnmr�
<br />ER Outpatient Residence
<br />Ob. FACILITY - Name /drwt /ns6tvow, give sheet and numw
<br />DOA ❑ Other (SPecrty) .,-...-- .- .........._...- ,.r..- .....�
<br />&, CITY. TOW OR LOCATION OF DEATH
<br />Bid INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH -�•� .- ._.,.__•.._
<br />Grand Island
<br />L Yeso No
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />ge. CITY, TOWN OR LOCATION 9d. STREET AND NUMBER pncluding Zip Code)
<br />9e INSIDE CITY LIMITS
<br />Yes Np ❑
<br />10, RA • (e.g., its. Black. American ndiK
<br />11, ANCESTRY (e.g.. Italian, Mexidan, ermen, etc
<br />1 MARRIED WIDOWED
<br />13. NAME OF SPOUSE (if wile. give maiden name/
<br />eta.) (Specify(
<br />White
<br />(Specify)
<br />Amr1117'eln
<br />NEVER DIVORCED
<br />1:1
<br />1
<br />14a. USUAL OCCUPATION /Give kWot work dprra cli most
<br />OF BU SINESS INDUSTRY
<br />15. EDUCATION ( Specify only highest grade completed)
<br />of worlrrn9 kte, even it /sired)
<br />1�01:fm
<br />Elementary or Secondary (0 -121 College 11 .4 or b • I
<br />18. FATHER. NAME FIRST MIDDLE LAST t7
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />18. WAS DECEASED
<br />EVER IN V.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />(Yes. no. or unk.)
<br />(II yes. give war and dates of services)
<br />NO
<br />19b, INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP)
<br />704 N. Custer Ave Grand Island, Nebraska 68803
<br />20, EM SI NA URE 6 L NSB N0.
<br />21a. METHOD OF DISPOSITION
<br />21 b. DATE
<br />_
<br />CEMETERY N7A-M�E.��
<br />,•
<br />�;IEFI,
<br />® Burial 11 Removal
<br />T21c.
<br />rY
<br />,�ORa,�CREMATORY
<br />as1a wt) L 3mrial Park
<br />r'.
<br />OME - NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY O STATE
<br />Dr"latim ❑Donaaon
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R,F,D. NO.. CITY OR TOWN, STATE, ZIP)
<br />391 q w- mprtb Front St lrbra�aa . 68803 _
<br />23 IMMEDIATE CAUSE IEN ALfSE'�ECSTIF7E'r �.i (a). (b), AND (cp Interval between onset and dP;atr,
<br />PART
<br />I(a) Respiratory due to disease,
<br />arrest chronic obstructive pulmnary
<br />DUE T0, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />I
<br />(bl
<br />DUE TO, OR AS A CONSEQUENCE OF: ._T I Interval between onset and dealt)
<br />I
<br />I
<br />(C) I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related ART
<br />III IF FEMALE. WAS THERE A
<br />AUTOPSY
<br />AS CASE REFERRED TO MEDICAL
<br />PART REGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER'
<br />r -�
<br />11 Con estive heart failure (Ages
<br />y
<br />/ 10 -541 Vas No
<br />Ve5 Nn
<br />Yes No
<br />268.
<br />26b. DATE OF INJURY (Mo.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />28d. DESCRIBE HOW INJURY OCCURRED
<br />Accident Undetermined
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />26f. PLAB E OFi INJURY - At g, larm, street, ladory
<br />ddhh buM ng, etc. (Specify,
<br />26g. LOCATION STREET OR H.F.D. NO. CITY OR TOWN STATF
<br />Homicide Investigation
<br />❑❑
<br />Yes No ❑
<br />a. DATE OF DEATH (Md.. Day. Yr-)
<br />28a. DATE SIGNED (Mo.. Day. Yr.)
<br />26b TIME OF DEATH
<br />�4
<br />November 4, 2002
<br />�i -�
<br />M
<br />it
<br />1�
<br />t1. DATE SIGNED (MV.. Da,: YC)
<br />c. TIME OF DEATH
<br />28C. PRONOUNCED DEAD (Mo.. Day. Yr.)
<br />28d, PRONOUNCED DEAD (Houa
<br />November U 9002 _
<br />o
<br />M
<br />g�x
<br />�
<br />d. To the best vl my know/ a urred at the beta��W
<br />2 8e. On the basis of examination and, or investigation. in my opinion death occurred at
<br />r
<br />� g
<br />�due
<br />causelsl stated.
<br />the time, date and place and due to the cause(s) stated.
<br />(Si tore and Title ) Iii,
<br />ISign.ture and Title) ► „...
<br />. DID TOBAPCO USE CONTRIBUTE TO THE DEATH? Ar
<br />HAS ORGAN.011 TISSUE DONAT
<br />CONSIDERED?
<br />WAS CONSENT GRANTED'/
<br />YES L1 NO 11 UNKNOWN ra
<br />❑ YES
<br />NO
<br />YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNFYI (Type or Print)
<br />Dr. W' g8n3
<br />32a. REGISTRAR
<br />-71 DATE FILED BYaFfVRAp ( ,Day�q�r�
<br />J
<br />
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