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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- RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL Ste_ i5_ ICS S_g_CMN, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE -
<br />w=
<br />MAY 12 2005 = - = fAIVLEi - -9;.-, COOPER
<br />C ry C ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA „�r 00 5 O (J O HEALTH AND HUMAW -SERV ICES
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPOR C- o r
<br />_. CERTIFICATE OF DEATH _ �� 4� 1 C7 J�
<br />1. DECEDENT'$ -NAME (First, Middle, Last, Suffix) 2" SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Nadine B1 Female 005 April 22, 2
<br />.. __ _
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday 56. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs.) MOS. DAYS HOURB MINS.
<br />Ilk, Malmo, Nebraska 60 May 10, 1944
<br />7. SOCIAL SECURITY NUMBER Us, PLACE OF DEATH
<br />507 -56 -7466 H06PLL: ❑ Inpatient � -B: UNursingHome /LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />❑ ER1Dutpallent Decedent's Home
<br />1103 East Street
<br />U DCA ❑ Other (Specify)
<br />So. CITY OR TOWN OF DEATH (Include Zip Code) COUNTY OF DEATH
<br />Wood River, 68883 all
<br />_.
<br />ga. RESIDENCE-STATE gb, COUNTY 9c. CITY OR TOWN
<br />n Nebraska Hall Wood River
<br />9d. STREETAND NUMBER APT, NO 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />1103 East Street 68883 50 YES ( NO
<br />V 10a. MARITAL STATUS AT TIME OF DEATH Z Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Lest, Suffix) If wife, give maiden name.
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Ken Bly
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) �12. MOTHEWS•NAME (First, Middle, Maiden Surname)
<br />Fred Odvody
<br />Helen Vaca
<br />13. EVER IN U "S. ARMED FORCES? Give dates of service if yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />? (Yes, no, or unk.) No Ken Bl Husband
<br />-- -- ._
<br />15. METHOD OF DISPOSITION 16 MER•SIGNATURE 16b. LICE SE N 16c, DATE (Mo., Day Yr. )
<br />38urlal C] Donation
<br />--,c' Aril 27 2005
<br />❑ Cremation ❑ Entombment 16d. CEM ERY, CREMA -0 Y OR OTHER LOCATION CITY / TOWN STATE
<br />' V
<br />El Removal ❑Other (Specify)
<br />St. Mary's Cemetery Wood River Nebraska
<br />-- ..... --- ._.... ..._.._. -.. _ - _.._.....
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Slate) 176. Zip
<br />Apfel Funeral Home, 411 West 11th St., P.O. Box 126, Wood River, Nebraska 68883
<br />" & +. 18. PART I. Enter the chain of events -- diseases, injuries, or compllcations••that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />I
<br />�J respiratory arrest, or ventricular fibrillation without showing the etiology" DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines II necessary. I
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In death)
<br />Sequentially list conditions, It
<br />any, leading to the cause listed
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that initiated
<br />the events resulting In death)
<br />LAST
<br />IMMEDIAT . AUSE: 0
<br />DUE T0, OR AS A CONSEQUENCE OF: �y
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />DUE T0, OR AS A CONSEQUENCE OF:
<br />(d)
<br />onset to death
<br />L_ ,
<br />I onsettodeath
<br />r (.. v-(" #.r
<br />onset to death
<br />1 onset to death .
<br />I
<br />._._. _._......... - -_. __....... ._.._ ......... _..
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS•Condillons contributing to the death but not resulting In the underlying cause given In PART I. 19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />Cl YES Q"NO
<br />20. IF FEMALE: 21a.MAI�PIEROFDEATH 21b.IFTRANSPORTATIONINJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />O'dot pregnant within past year Natural ❑ Homicide ❑ Driver /Operator
<br />❑ YES
<br />• Pregnant at time of death G Accident❑ ❑ Passen er pending Investigation 9 _
<br />• Not pregnant, but pregnant within 42 days of death Li Pedestrian
<br />❑ Suicide ❑ Could not bedetermined 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />❑Other (Specify)
<br />El Not pregnant, but pregnant 43 days to 1 year before death COMPLETE CAUSE OF DEATH?
<br />❑ Unknown It pregnant within the past year ❑ YES 1111-9�0
<br />22a. DATE OF INJURY (Mo.. Day, Yr) 2Pb. TIME OF INJURY 22c. PLACE OF INJURY -Al home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d.INJVRYATWORK? 229. DESCRIBE HOW INJURY OCCURRED
<br />(3 YES El NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CRY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />x
<br />4r 23b.DATESIG ED(Mo.,Day,Yr.) 23c.TIMEOFDEATH
<br />Ear c m
<br />z
<br />°
<br />23d, To the hest of my knowledge, death occurred at the lime, data and place
<br />a and due to the causes) ssI I d ( Signature and Title) T
<br />o m /
<br />_ STATE ZIP CODE
<br />y 24a. DATE SIGNED (Mo,, Day, Yr.) 241b.TIME OF DEATH
<br />AJz m
<br />W_...... _.. -_
<br />a Im 24c. PRONOUNCED DEAD (Mo., Day, Yr,) 24d " TIME PRONOUNCED DEAD
<br />x
<br />M m
<br />Em i x
<br />Lu ° 24e. On the basis of examination and /or Invesllgallon, In my opinion death occurred at
<br />J% ¢ 0 the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />U
<br />a ti;' 25.DIDTOBAC00USE CONTRIBUTETOTHEDEATH? / 1 258" HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />�-i ❑YES � /N_0_ ❑ PROBABLY ❑ UfJJ£tiOWN ❑ YES 'E'�"NO Not Applicable 1126e _Is NO DYES L��-"NO
<br />r') 27. NAME TITLE D qD R S OF CERTIFIER (PH ICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) U- t op r MD
<br />y�,,�{ / J
<br />'��% � 1._..:£t. Francis Cancer _Treatment Center Grand Island NE 6880
<br />28a. REGISTRAR'S SIGNATURE
<br />28b" DATE FILED BY REGISTRAR (Mo., Day, Yr,)
<br />MAY 9 2005
<br />
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