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<br />
<br />STATE OF NEBRASKA
<br />
<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 R~(;();ftRJNIfIJ..E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS.l,!Ci{!!fiCllciNy..wfflCH IS
<br />
<br />::;:::~S::E~RY FOR VITAL RECOROS. ~~~
<br />SEP 2 8 2005 2006010 51 AS$!ST~TST~7E71Er;I$"}illf8
<br />HEAl..l:HJit(P>#J.~Alj4p~V,-q~
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<br />
<br />._._... STATEoFNEaRAsKA~~_EPAR~~~D~~~~;~N~~U~~~~~V'CEsF'N~~eA~~~i5RTO 5 .097 3 9..~
<br />
<br />1. DECEDI,NT'S.NAME (FirS!, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Dey, Yr.)
<br />.---. Gary ..._~ ..Fr~ahm._ Male Au u_st 23, 2llil5.
<br />4. C...IT. Y. AND STATE .O..R TERRITORY, O.R FOREIGN C.OU.NTRY OF BIRT..H. "' ~::;"" ,,,,,",, '~::p:::" :;,~:'"';:: """, """ ,"0, '''' ",
<br />
<br />__Grand Island,_Ji.e.hrasb '__ 47 _ Sept.. 15. 19.'5]
<br />7. SOCIAL SECURITY NUMBER ra. :~::I~:I DEATH -
<br />o Inpatlenl Q!ltiJ: 0 Nursing Home/LTC 0 Hospice Feclllty
<br />
<br />(j ERIOutpatlenl 0 Decedenl's Home
<br />
<br />St. Francis Medical Center 0 IXJI\ OOlher(Specily)------o-.___...
<br />-_.'",~-----,
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />Bc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />
<br />8d. COUNTY OF DEATH
<br />
<br />Hall
<br />
<br />9a. RESIDENCE.STATE
<br />
<br />9b. COUNTY
<br />
<br />90. CITY OR TOWN
<br />
<br />M;ii':';::"L: S-"Eeet Ha~ =- Grandr"r^~,1,~ni~~'8';~1
<br />
<br />
<br />10a. MARITAL STATUS ATTIME OF DEATH 0 ~Never Merried lOb. NAME OF SPOUSE (First, Middle, La,t, SlIfflx) If wile, give maiden name.
<br />
<br />--'--.~INSIDE. CITY LlMITS-
<br />~YES 0 NO
<br />
<br />o Married, blll 'eparated 0 Widowed 0. Divorced 0 Un~nown
<br />
<br />'S.'lIf:=EIX) 12. MOTHER'S.NAME '(F1r~;,
<br />Alice
<br />~,~,~, .
<br />13. EVER IN U.S. ARMED FORCES? Give dales of .ervlcell yas. 14e.INFORMANT.NAME
<br />
<br />no
<br />
<br />11. FATHER'S.NAME (Flrsl,
<br />Henry
<br />
<br />Middle,
<br />
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />
<br />o BlIrial U Donation
<br />dicremellon 0 Entombmenl
<br />
<br />N p_t. Emba lm_e~
<br />t6d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY /TOWN
<br />
<br />Sailing __
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />'- Aunt
<br />16c. DATE (Mo" Dey, Yr. )
<br />
<br />.Aug. 24, 2005 ~..
<br />STATE
<br />
<br />Wi I li.J-1ms
<br />
<br />16a. EMBALMER.SIGNATURE
<br />
<br />lBb. LICENSE NO.
<br />
<br />o Removal 0 Olhar (Specify)
<br />
<br />Cen tr~l N el:Jr_<3,ska G.!:.~ma tion_Service
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Streel, Cily or Town, Slele)
<br />All Faiths Funeral Home
<br />
<br />IMMEDIATE CAUSE: onsello dealh
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease Or condition resulting
<br />In death)
<br />
<br />(a) GUNSHOT WOUND
<br />
<br />~~.MMEDIATE
<br />
<br />onsello dealh
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Sequentially tist conditions, If (b)
<br />eny,lo.dlng to the Call'e Ii.ted - DUE TO, OR AS--;' CONSEQUENCE OF: .
<br />on line a.
<br />Enter Ihe UNDERLYtNG CAUSE
<br />(dl.e... or Injury thallnillated (c)
<br />the events resulting In death) ------ouETO, OR AS A Co'NSEO'UENCE OF:
<br />IJ\ST
<br />
<br />onsst 10 death
<br />
<br />(d)
<br />
<br />-...I.~
<br />I onsetto deelh
<br />I
<br />I
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to Ihe death blll not re,ulllng In Ihellnderlying cau.a glvan in PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />~ YES 0 NO
<br />
<br />20. IF FEMALE:
<br />
<br />21 a. MANNER OF DEATH
<br />o Nalural U Homicide
<br />
<br />21b. IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />DDriverlOperalor
<br />
<br />o Passenger
<br />
<br />DYES
<br />
<br />~O
<br />
<br />U NOI pregnant within pe51 yeer
<br />o Pregnant el lime of dealh 0 AccldentO Pending Invesllgallon
<br />o NOI pregnant, but pregnenl within 42 day. of dealh Il!l SlIlclde 0 COllld nol be delermined 0 Pede.lrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Nol pregnant, bllt pregnent 43 days to 1 year before dealh 0 OIher (Specify) COMPLETE CAUSE OF DEATH?
<br />
<br />o Un~nown II pregnanl within the pa51 year U YES XQS NO
<br />
<br />-22~:~~; I~JU;Y~(MO' ~Q'Qr~ "'~i~rtr~f d~ ;~C;OF"iNJURY'Ath::e, term, ~ir~~t, faCIOrY'~ff1Ce_blllldlng'-~o~;;;uction 511::elc. (Sp'-~ity)"'-
<br />
<br />22d.INJURY AT WORK? 22a. DESCRIBE HOW INJURY OCCURRED
<br />
<br />[) YES l:9 NO
<br />
<br />suicide (gunShot to head)
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />303 E 6th
<br />
<br />CITYIfOWN
<br />Grand Island
<br />
<br />STiIrE
<br />
<br />,. ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo" Day, Yr.)
<br />A~.9.u_s t 23. 2Q95
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />
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<br />
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<br />
<br />23c. TIME OF DEATH
<br />
<br />23d. To the be.1 01 my ~nowledge, dealh occurred allhe time, data and piece
<br />and duelo the ca1l5e(5) 5laled. (Signatura and Tille) "
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TOTHE DEATH?
<br />
<br />26e. HAS ORGAN OR TISSUE DONATION
<br />
<br />o YES )tlI. NO
<br />
<br />NE 68801 Deputy Coroner
<br />
<br />28b. OATF. FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />SEP
<br />
<br />1 2005
<br />
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