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200509431
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT 315971
<br />CFRTIFICATF nF nFATW
<br />1. DECEDENT'S -NAME (First, Middle. Last,
<br />Suffix) 2, SEX
<br />3. DATE OF DEATH (Mo.. Day. Yr.)
<br />neEtta Brand
<br />Female
<br />January 1 20051
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH I Sa, AGE -Last Birthday
<br />7YES Q NO i
<br />Sb, UNDER 1 YEAR
<br />I St:. UNDER i DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr,)
<br />Stromsburg, Nebraska (Yr..)
<br />Q'Not pregnant within past year
<br />dlawrearcatdlim ttwq
<br />MOB DAYS
<br />HOURS
<br />MINS.
<br />61
<br />I
<br />3 4 It so teem 8
<br />lb) S K `
<br />a Not pregnant, but pregnant within 422 days of death
<br />February 19, 1943
<br />7. SOCIAL SECURITY NUMBER
<br />p. PLACE OF DEATH
<br />505 -48 -1693
<br />HOSPITA
<br />:1 inpatient OM a NursinyHo e&TC a Hospice Facility
<br />C7 ER 1pupatsm a D.n.drd a Ham
<br />Sb. FACILITY -NAME (If not institution, gnq street and number)
<br />University
<br />Nebraska Medical Center
<br />o ooa a Other ( ,
<br />8c. CITY OR TOWN OF DEATH (IwJ de Zip Code)
<br />: onset 10 death
<br />ad. COUNTY OF DEATH
<br />Omaha
<br />221f.QESCRIBE NOW INJURY OCCURRED
<br />Douglas
<br />ft RESIDENCE -STRE
<br />a0. OOIMVTY
<br />Ills, CITY Oai 11
<br />TDW
<br />Nebraska
<br />Hall
<br />Grand Island
<br />USTRIETANDNUMBER
<br />Be. APT. NO
<br />R. ZIP CODE
<br />dg. INSIDE CITY LIMITS ,
<br />4232 Nordic Road
<br />2b DATE sIPNED Rk. Dry. Yr.) G 24c. PRONOUNCED DEAD (M0.. a7• Yr.) 241. TB,E PRONOUNCED DEAD
<br />68803
<br />t 16 YES a No
<br />10s. MARITAL STATUS AT TIME OF DEATH n tdarried a Nipper Married
<br />10b. NAME OF SPOUSE (Fkat, Middle. Last Suft) Narita, gfw maiden maw,
<br />a Married, but esparated a Widowed a DWacad a unknown
<br />Jerome H. G r a n d
<br />11. FATHER'S -NAME (First. Middle. Last, Suffix)
<br />MOTHER•S•NAME (First, Middle, Maiden Surname)
<br />Henry Smith
<br />112.
<br />Jessie Cove
<br />19. EVER IN U.S. ARMED FORCES? Ghre dates of service A yes.
<br />INFORMANT NAME
<br />286. WAS CONSENT GRANTED?
<br />14b. RELATIONSHIP TO DECEDENT
<br />(Yes, no. orunk -) No
<br />114a.
<br />Jerome H.
<br />Brand
<br />1S. METHOD OF DISPOSITION
<br />19x.
<br />16b. LICENSE NO-
<br />I So. DATE (Mo.. Day, Yr.)
<br />M Surw o Donation
<br />H^.�k7
<br />0anuary 5, 2005
<br />I S;. CEMETERY, CREMATORY OR OTHER L TION
<br />CITY I TOWN STATE
<br />❑ Crrnation Q Enfombi,,W&
<br />oRenlwn! o Other (Spa*)
<br />Westlawn Memorial Park
<br />Grand Island, Nebraska
<br />17s FUNERAL HOME NAME AND MAILING ADDRESS (StreeL CRy orTown, State)
<br />17b. Zip Code
<br />1B, PART I. EItt r the -- dwasN, injur" Of camp8catlarr -that dMeetly caused IM OOW 00 NOT VW W WA W apuas such r cardac urreM
<br />/WPROXIINITE INTERVAL
<br />reapkatM arrest, a vwmtular 8bribtion without siiuwinp the etiology, 00 NOT ABBREVIATE. Enter only ate cause on a I1m. Add additiolW Ilse I necessary.
<br />OR CORONER CONTACTED?
<br />IMMEDIATE CAUSE
<br />also 10 deaN
<br />7YES Q NO i
<br />BI CaA ol, at ¢ fA4_"_k
<br />21 a. MANNER OF DEATH
<br />IIIIIIIEDIATECAUBEow
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />Q'Not pregnant within past year
<br />dlawrearcatdlim ttwq
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />I Oros! to death
<br />Ndsa�
<br />U Accider;Q Perldmg Imrosagstion
<br />I
<br />3 4 It so teem 8
<br />lb) S K `
<br />a Not pregnant, but pregnant within 422 days of death
<br />Way. Nwdltq 10 go Catra head
<br />DUE 70, OR I]UENCE OF
<br />-�
<br />I onset to death
<br />on 8tte a.
<br />Enter the
<br />45 ; <G
<br />COMPLETE CAUSE OF DEATHI
<br />aa`I4 dice
<br />(C) ,e 1.4 11" © <<
<br />NaserrwearwalMtlrgNdaMi1
<br />DUE TO, OR AS A CONSCOLIENCE OF:
<br />: onset 10 death
<br />U!F
<br />22d. IN.AIRY AT WOP0
<br />221f.QESCRIBE NOW INJURY OCCURRED
<br />Id)
<br />'
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in tie underlying cause groan in PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />h
<br />�. (t.lQ V' �fQ �� j� (CL Ll.� X Z
<br />OR CORONER CONTACTED?
<br />/
<br />7YES Q NO i
<br />20. IF FEMALE:
<br />21 a. MANNER OF DEATH
<br />21b. IF TRANSPORTATION INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />Q'Not pregnant within past year
<br />211aturai a Homicide
<br />a OrWX*0r r
<br />VYES 0 NO
<br />LJ Pregnant at time of death
<br />U Accider;Q Perldmg Imrosagstion
<br />OPa>AergK
<br />214- WERE AUTOPSY FINDINGS AVAILABLE TO
<br />a Not pregnant, but pregnant within 422 days of death
<br />❑ SuiciuM a CoWd not be ceNrmYied
<br />a Padestrfan
<br />• Not preg sere, but pregrard 43 days lot year boars deed
<br />� OU1r (Specify)
<br />COMPLETE CAUSE OF DEATHI
<br />• Unimumn it pregnant within the Pap year .
<br />U YES a NO
<br />223. DATE OF INJURY (Mo,. Day, Yr.)
<br />M. TIME OF INJURY
<br />m
<br />22C. PLACE OF INJURY -At ham• farm, cereal, factory office building, Construction sue. etc. (Specify)
<br />22d. IN.AIRY AT WOP0
<br />221f.QESCRIBE NOW INJURY OCCURRED
<br />C3 YES a NO
<br />i
<br />22L LOCATION OF INJURY - STREET A NUMBER. APL NO, CI Y/TOppN
<br />- SWE 21P CODE
<br />,
<br />D" Yr.) 21b. TIME OF DEATH
<br />23ff GATE OF QBA ( rY ► 240.
<br />DATE SIGNED (M&,
<br />a t . m• v e .. a ;' a
<br />m
<br />2b DATE sIPNED Rk. Dry. Yr.) G 24c. PRONOUNCED DEAD (M0.. a7• Yr.) 241. TB,E PRONOUNCED DEAD
<br />23d. To title_ d my . Oath otxuned atilldntlme, d4le.find place 24.
<br />3
<br />On the bps of examination, rdiot invngtlgNial, in my opinion death oco rred at
<br />71111e
<br />and a<"krO dhe od. Ift"b" s l T (n; i
<br />IM f1me, date and piece and due to this cwWs) stated. (Signature and )
<br />2S. DIDTOBACCO TOTHE
<br />28x: S ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />286. WAS CONSENT GRANTED?
<br />,y y
<br />C3 YES i�7'f40 �+^ t , r } b UNKNOWO"'
<br />a YES Q1 'NO
<br />Not Applicable if 26a is NO a YES Z'NO
<br />27. NAME, TITLE AND AOl7H C.ERTIFIkN (TY'y-)Iilrap, K5 YFIY43R,WI UH V AM 1 T Al 11LMYCT) t 1YPe Or M1111
<br />28LREGtSTRARSSI135f4h -J f..ke 2tW. DATE FILEDBYREGISTRAR (Mo..Oay,Yr.)
<br />JAN 13 20x5
<br />This certifies this document to be a true copy of an original record on file with Vital Statistics, Douglas County
<br />Health Dept., Omaha, Nebraska. Certified copies must have a raised seal in the area to the left. Reproductions
<br />of this green certificate are not legal copies.
<br />JAN 13 2 AJS�_�
<br />Date Issued: Registrar: u11�
<br />
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