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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 CERTIF'IE'S THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE-G -Q 1- _dN'FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATTIGSAE'9!TI Pk-WHICH is
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />AUG 2 5, 2005 2 V 0 60 0 (3 - - TAME €YS_ COOPER
<br />-� ASS /STAI11F3 7"E=REGISTRAR
<br />LINCOLN, NEBRASKA REAL,TH A_ND H CES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND.SLA ROHT
<br />CERTIFICATE OF DEATH
<br />0-q 3
<br />- -....
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mc., Day, Yr.)
<br />Cathleen_ -. Ann __Ogde Female Au ust_11, 2005
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Last Birthday 5b. UNDER 1 YEAR 6o. UNDER 1 DAY 6, DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs.) MOS. DAYS HOURS MINS.
<br />Fremont, Nebraska 60 January 5, 1945
<br />7. SOCIAL SECURITY NUMBER ea. PLACE OF DEATH
<br />506 --52 -0972 HOSPITAL: El Inpatient OTHER L:1 Nursing Home /LTC ❑ Hospice Facility
<br />8b. FACILITY•NAME (If not institution, give street and number)
<br />St. Francis Medical Center
<br />6c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island, Nebraska 68803
<br />9a. RESIDENCE -STATE 9b. COUNTY 9c. CITYOR TOWN
<br />Nebraska Hall Grand Island
<br />9d _ .._ ..
<br />STREET AND NUMBER 9e, APT, NO 9f. ZIP CODE
<br />13 Cherokee 68803
<br />10a. MARITAL STATUS AT TIME OF DEATH 10 Married ❑ Never Married 10b. NAME of SPOUSE (First. Middle, Last, Suffix) If wife, give maiden name.
<br />❑ Married, but separated ❑ Widowed U Divorced ❑ unknown Larry Ogden
<br />CXER /Oulpationt ❑ Decedent's Home
<br />❑ DCk ❑ Other(Specify) ____,
<br />8d. COUNTY OF DEATH
<br />I Hall .,.,._._.._
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle,
<br />Meril L. Curtis F
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. 14a. INFORMANT -NAME
<br />(Yes, no, or unk.) _ No Larry Ogden
<br />15. METHOD OF DISPOSITION 16a. F. 1,ALMER- SIGNATURE
<br />IN Burial C1 Donation d l 't_..rC.,�. ,1 ,,r .�.,r_�L.._ „r..,�. -•
<br />❑ Cremation ❑ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />❑Removal LJOther(Specify) Grand Island City Cemetery
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />9g. INSIDE CITY LIMITS
<br />W YES ❑ NO
<br />Malden Surname)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />16b, LICENSE NO. 16c, DATE (Mo., Day, Yr, )
<br />August 16 , 2005 _
<br />CITY / TOWN STATE
<br />Grand Island, Nebraska 68803
<br />Livingston- 5ondermann Funeral Home, 601 North Webb Road. Gr
<br />17b. Zip Code
<br />NE 68!
<br />18. PART 1, Enter tho chain of events -- diseases, injuries, or complications- -that directly caused the death, DO NOT enter terminal events Such as cardiac arrest, APPROXIMATE INTERVAL
<br />1
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only
<br />one cause on a line. Add additional lines if necessary. I
<br />IMMEDIATE CAUSE:
<br />1 onset to death
<br />I
<br />(a) ardiopulmionary arrest
<br />15
<br />IMMEDIATE CAUSE (Final -_C
<br />minutes
<br />ea
<br />disease condition resulting DUE TO, OR AS A CONSEQUENCE OF:
<br />onset to death
<br />in death)
<br />in death)
<br />I
<br />Sequentially list conditions, if (b) Hypertension
<br />unknown
<br />any, leading to the cause listed
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />I onset to death
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that initiated (c)
<br />the events resulting in death) DUE TO, OR ASACONSE gUENCE OF:
<br />__... 1 l
<br />tinsel to death
<br />LAST
<br />(d)
<br />-_
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the
<br />underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />Gangrene of lower legs
<br />`DYES ❑ NO
<br />20. IF FEMALE: 21a. MANNER OF DEATH
<br />21b.IFTRANSPORTATIONINJURY 21o. WAS AN AUTOPSY PERFORMED?
<br />91 Not pregnant within pasl year XII Natural ❑ Homlcide
<br />❑ Driver/Operator
<br />Cl YES )XNQ
<br />C3 Passenger
<br />U Pregnant at time of death Cl Accident❑ Pending Investigation
<br />q Not pregnant, but pregnant within 42 days of death ❑
<br />9ulclde ❑Could not be determined
<br />C1 Pedestrian
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />C1 Not
<br />Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ (Specify) COMPLETE CAUSE OF DEATH?
<br />❑ Unknown If pregnant within the past year
<br />❑ YES 000 NO
<br />22a. DATE OF INJURY (Me., Day, Yr.) 22b, TIME OF INJURY 22c. PLACE OF INJURY -At home,
<br />farm, street, factory, offloe bullding, construction site, etc. (Specify) _
<br />22d. INJURY ATWORK? 22e, DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY • STREET 6 NUMBER, APT. NO. CITYITOWN
<br />STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />z a
<br />- �yUZ
<br />uz
<br />August 17 2005 8:58 aT,
<br />r 23b. DATE SIGNED (Mc., Day, Yr.) 23o. TIME OF DEATH I = �
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />s
<br />IT) Er; z
<br />�o
<br />August 11, 2005 9:15 am
<br />v
<br />23d. To the best of my knowledge, death occurred at the time, date and place w =
<br />249.On the basis of examination and /or Investigation, In my opinion death occurred at
<br />and due to the causes) slated. (Signature and Title) ♦ o a U
<br />the lima, to/anlace and due to the cause(s) staled. (Signet eafid Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b.WA N TGRANTE.D?
<br />C3 YES )l NO 11 PROBABLY U UNKNOWN El YES 6 NO No6pplicable If 26s is NO ❑ YES �] NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONFR'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Mark J. Young, Hall Cou ty Attorney, 231 S. Locust St, Grand Island NE 68801
<br />28a. REGISTRAR'S SIG U E 28b. DATE FILED BYREGISTRAR (Mo., Day, Yr.)
<br />AUG 2 4 2005
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