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<br />'.
<br />
<br />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 F1LE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS sgffON.~ViJilGl!IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~~:1--~?~=c~~.:!~'-
<br />
<br />DATE OF ISSUANCE fV~' ~WJ!~~~~. e:;~[~\
<br />SEP 2 2 2005 200511464 ASSISTANTS.,ATEREGlsTI3AR. ..~
<br />LINCOLN, NEBRASKA HEALTH ~D H!I"-Jl' SE~~~/S."-= j}
<br />
<br />0;. '-,.' .":,. ';, ,::.~,=~=. c co'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AM:> S~_...p.~ O.'frr'.- '.-.-: D.,..iL.S.'.--':'" '.fO'--- 3 5 6
<br />CERTIFICATE OF DEATH ~'-- _,,:,:' .'. .'-' __
<br />DECEDENT'S-NAME (First, Middle, Lasl, Suffix) 2. SEX 3:DATEDFDEATH (Mo., Day, Yr.)
<br />Anna Belle Whitehead Female September 16, 2005
<br />
<br />q
<br />
<br />.~
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a. AGE-Le.t Birthday 5b. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />85
<br />
<br />5c. UNDER 1 DAY 6. DATE OF BIRTH IMo., Day, Yr.)
<br />HOURS lMINS:- October 3, 1919
<br />
<br />Greeley, Nebraska
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />505-12-2712
<br />
<br />Ba. PLACE OF DEATH
<br />I::I.QSEJIAJ.: J1( I n palle n t
<br />
<br />Qlliffi: 0 Nursing Home/LTC [) Hospi," Faclllly
<br />
<br />Bb. FACILITY. NAME (If nol Inslltullon, give slr..1 and number)
<br />
<br />o ERlOutpall.nl
<br />
<br />o Deced.nt's Hom";
<br />
<br />Saint Francis Medical Center
<br />
<br />[l 000. 0 Other (Specify)
<br />
<br />--r ~~O~~YOF DEA~H
<br />
<br />8c. CITY OR TOWN OF DEATH Ilnclude Zip Code)
<br />Grand Island, 68803
<br />
<br />;;;;::~=~-'-'---'---=19~C~~~
<br />
<br />9d. STREET AND NUMBER
<br />818 West 14th St.
<br />
<br />ge. CITY OR TOWN
<br />Grand Island
<br />
<br />
<br />91. ZIP CODE
<br />68801
<br />
<br />n_"-TI---
<br />. 99... IN. SIDE CITY LIMITS
<br />III YES 0 NO
<br />
<br />'IOs. MARITAL STATUS AT TIME OF DEATH [J Marri.d [l N.II.r Married lOb. NAME OF SPOUSE IFlrst, Middle, Lasl, Sulflx) If wite, give maiden nam..
<br />
<br />U Married, but seperated J1(Wldowed 0 Dlllorced 0 Unknown
<br />
<br />11. FATHER'S-NAME (Flrsl,
<br />George
<br />
<br />Middle,
<br />A.
<br />
<br />Last, Sutrlx)
<br />Crumrine
<br />
<br />12. MOTHER'S-NAME (FirSI,
<br />Pearl
<br />
<br />Middle,
<br />M.
<br />
<br />Malden Surname)
<br />Moore
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />SOn
<br />
<br />16c. DATE (Mo., Day, Yr.)
<br />Ssp 19, 2005
<br />
<br />J1(Cremallon 0 Entombment
<br />o Ramollal o Other (Speclly) Central Nebr. Cremation Servic Gibbon
<br />
<br />STATE
<br />
<br />NE
<br />
<br />Zip Coda
<br />
<br />PART i. Ente, the mo.~--dlseas.s, InJuries, or compllcatlon'nthat dlr.Olly caused Ihe death. DO NOT .nl.r termlnel allents such a. cardiac arteSI,
<br />respiratory arrest, or vp.ntdcLJIAr fibrillation wllhout ghowlng the etIology. DO NOT ABBREVIATE, Enter only one cause on a line. Add addillonallines il necessary,
<br />
<br />IMMEDIAT~ CAUSE:
<br />
<br />onset to death
<br />
<br />IMMEDIATE CAUSE (Flna'
<br />dlsu8tl or condition resulllng
<br />in doath)
<br />
<br />Sequentially 11.1 condition., II (b)
<br />any, leading 10 the oauoell91ed DUE TO, OR AS A CONSEQUENCE OF:
<br />on line a.
<br />Enterll>a UNOER~YJNG CAUSE
<br />(dls.ase or injury thatlnlllat.d (c)
<br />theellentsresultlng In death) . DU~ TO, OR AS A CONSEQU~NCE OF:
<br />lASr
<br />
<br />~C~~_ II A:r u.A t;.4A
<br />
<br />DUE TO, OR AS A CONS~QUENCE OF:
<br />
<br />hC-l/Jwl
<br />. "..
<br />
<br />s-- ~~!J..__._-
<br />
<br />onoet to death
<br />
<br />on..t 10 d.ath
<br />
<br />onsel to death
<br />
<br />(d)
<br />
<br />V (>r~_t/ t..I. c4A.
<br />20. IF FEMALE:
<br />() Not pregnant within past year
<br />b pr.gnant al time of death
<br />o Nol pregnant, but pregnonl wllhin 42 days of deeth
<br />o Not pregnanl, bUI p,egnant 43 days to 1 yaar b.fore dealh
<br />o Unknown If pr.gnanl wilhin the pasl year
<br />
<br />y( L4;tr t1~ J W r
<br />
<br />.C:M~
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />[l YES J1( NO
<br />
<br />PART Ii. OTHER SIGNIFICANT CONDITIONS.Condltlons contributing to tho daath but nol r.,ulllng In the underlying cause given In PART I.
<br />
<br />o Suicide 0 Could nol ba d.l.rmln.d
<br />
<br />21 b. IF TRANSPORTATION INJURY
<br />o Drlller/Operetor
<br />
<br />o P....nger
<br />
<br />o Pedastilen
<br />
<br />o Olher (Specify)
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />21.. MANNER OF DEATH
<br />KNetural 0 Homlcld.
<br />
<br />o AccldentCl Pending Invosllgallon
<br />
<br />DYES J1( NO
<br />
<br />2td. WERE AUTOPSYFINDINGS AVAILABLETO
<br />COMPLETE CAUSE OF DEATH?
<br />o Y~S 0 NO
<br />
<br />22e. DATE OF INJURY (Mo.. Day, Yr.)
<br />
<br />22b. TIME OF INJURY
<br />
<br />22c, PLACE OF INJURY.At home, farm, street,laclory, office building, construcllon slle, elc. (Specify)
<br />
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />22.. DESCRIBE HOW INJURY OCCURRED
<br />
<br />o Y~S 0 NO
<br />
<br />22t.I.OCA:rION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CrrY/fOWN
<br />
<br />STPJE
<br />
<br />ZIP CODE
<br />
<br />Z4a. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />"'>-
<br />~~~
<br />n~~
<br />8ffi~0
<br />11"'0
<br />~~u
<br />8 is
<br />
<br />m
<br />
<br />24C. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e, On the basis 01 eJ<amlnalion and/or Investigation, In my opinion death occurred at
<br />the lime, data and place and duo to Ihe ceuse(s) stat.d. (Signatu,e and Title)"
<br />
<br />260, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />o YES ~ 0 PROBABLY (J UNKNOWN Q Y~S ]X NO
<br />"27:NiiM~: TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONEf6l'PHYSICIAN OR COUNTY ATIORNEY) (1\1pe or Prlnl)
<br />David R. Colan MD 729 N. Custer AV, Grand Island, HE 68803
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />Not Applicable 11.26e is NO lJ YES ~_JB:._~~
<br />
<br />~\ 28a.REGISTRAR'SSIGNATURE
<br />
<br />
<br />
<br />~~
<br />
<br />
<br />2ab. DATE FILED BY REGISTRAR IMo., Day, Yr.)
<br />
<br />SEP 2 0 2005
<br />
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