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WHEN THIS COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEMt IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ONM WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTI_QNe _.. IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />ANLEY 5:OOPER
<br />10/29/2003 200507924
<br />ASSISTANT SMM ��IST, t
<br />LINCOLN, NEBRASKA _HEALTHANDHUMAN_SERVICES
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICE I<I AMPORT
<br />VITAL STATISTICS = = 0
<br />CERTIFICATE OF DEATH = .'
<br />[1, DECEDENT • NAME FIRST MIDDLE LAST 2. SEX 1 DATE OF DEATH (Month. Day. Year)
<br />Mark Allen Sherman Male September 16, 2003
<br />4. CITY AND STATE OF BIRTH It'notin USA. name country/ Sa, AGE - Last Blrihday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Month. Day. Year/
<br />Loup Clay, Nebraska (Yrs,l 43 5b. M05.1 DAYS 5c. HOURS' MINS.
<br />IDecember 29, 3.959
<br />7, SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH
<br />140-58-2564 HOSPITAL: Inpatient OTHER: ❑ Nursing Home
<br />eb. FACILITY - Name (u not m9Ntution. give sheet and number) ❑ ER Outpatient ❑ Residence
<br />Nebraska Methodist Hospital ❑ DOA ❑ Other(Soecdv)
<br />6c_ TOWN OR LOCATION OF DEATH Bd. IIJSIOE CITY LIM! FS I 8e. COUNTY OF DEATH T
<br />Omaha Yes [X] No ❑ Douglas
<br />11157
<br />! 9a. RESIDENCE • STATE
<br />9b. COUNTY
<br />go. CITY, TOWN OR LOCATION
<br />9d. STREET ANp NUMBER (including p Code)
<br />Hall
<br />A 1 d a
<br />6662 Wildaood Lam. 68810
<br />7INSINebraska No ❑
<br />10. RACE • (e,g., White. Black. American Indian,
<br />11, ANCESTRY Ie.g.. Italian. Mexican, German, ate)
<br />12. MARRIED
<br />❑ WIDOWED
<br />13. NAME OF SPOUSE Pr wire. give maiden name)
<br />! etc,) I5pecily) Whit a
<br />(Specify( American
<br />NEVER
<br />DIVORCED
<br />Vicki Vogt
<br />MARRIED
<br />14a. USUALOCCUPATION /Give kind o /work done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Spedafy only highest grade completed)
<br />of working life, even i /retired!
<br />Production
<br />IAMS Pet Foods
<br />Elementary or Secondary 10 -121 College It -4 or 5•I
<br />12
<br />16. FATHER -NAME FIRST MIDDLE
<br />LAST
<br />17. MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Norman Sherman
<br />Deana Henrichs
<br />18. WAS DECEASED EVER IN U,S, ARMED FORCES?
<br />19a, INFORMANT •NAME
<br />(Yes. no, or unk.) (II yes. give war and dates of services)
<br />No 1
<br />Vicki
<br />Sherman
<br />1911, INFUHMANI MAILINI, AUUHCy.7 161 HCCI UM M.r.U, NU., LII Y UH IUWN. 31 A 1,"If
<br />6662 Wildwood Dr., Alda, Nebraska 68810
<br />20. EMBALMER - SIGNATURE e- LICENSE NO. 21 a. METHOD OF DISPOSITION 21b. DATE 210, CEMETERY OR CREMATORY NAME Burial Alda d a C em E t e y S V o ,
<br />2 . FUNERAL HOME - NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home ❑Cremation ❑Donation Alda, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP)
<br />12929 S_ Locust St., Grand Island, Nebraska 68801
<br />1 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Ial. (b). AND fell interval between onset and death
<br />PAP
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />I
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE, WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER?
<br />II -
<br />(Ages 10 -54) Yes 11 No 7 Yes 7 No Yes No
<br />26a. 26b. DATE OF INJURY (Mo.. Day. Y6) 280. HOUR OF INJURY 26d. DESCRIBE HOW WaJRY OCCURRED
<br />❑ Accident ❑ Undetermined M
<br />Suicide Pending 26e, INJURY AT WORK 281. P1�ACE QF INJURY -At hoJ�J11e, farm. street. factory 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />❑ ❑ d ee budding. ate. / pectry/
<br />I � Homicide Investigation Yes No
<br />27a. DATE OF DFATH (Mo.. Day. Yr.) 28a. DATE SIGNED /Mo.. Day Yrl 28b TIME OF DEATH
<br />September 16, 2003 _ M
<br />27b. DATE SIGNED (Mo.. Day. Yr.) 27c, TIME OF DEATH r i c r 28c. PRONOUNCED DEAD (Mo. Day, Yr) 28d. PRONOUNCED DEAD (Hourl
<br />G 3 2:06 P M !m M
<br />r. 27d. To the beat of my knowled occurred at the e, date and place and due to the ° cg 28e. On the basis of examination and, or investigation, in my opinion death occurred at
<br />causes) stated. S the time. date and place and due to the cause(s) stated.
<br />(Si nature and Tit r w (Si nature and Title
<br />29, DID TOBACCO U5E CON UTE TO THE DEATH, 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED?
<br />❑ YES r~1�4,140 ❑ UNKNOWN ❑ YES L&NO ❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY) t7ype dr Print/
<br />140 Lo $ --3 :3 ` L; +e 0,5n 0 h c tj E 1, F51 1
<br />$2a. REGISTRAR r 32b. DATE FILED BY RE ISTRAR (Mo.. Day. Yr)
<br />OCT -_ 6 2003
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