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<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_ RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT-IP1CS$tt-~ WHICH IS
<br />
<br />::::::~:ffORY FOR V'TAL RECORDS. ~~ER ..
<br />JAN 1 7 20013 rASS/mNTmttliREO/STRAR
<br />LINCOLN, NEBRASKA 2 0 0 6 0 16 3 4 'fI,EAi,[H AND HUMA"fSEFjV,ICES
<br />
<br />
<br />'f
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANgg'AI'IDOs
<br />CERTIFICATE OF DEATH
<br />
<br />
<br />of ~~~-2 0 11 2
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a. AGE.I.-ast Birthday 5b. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />93
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />S. DATE OF DEATH (Mo.. Day, Yr.)
<br />
<br />(~-'l[J:h
<br />
<br />6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />
<br />DECEDENT'S.NAME
<br />
<br />(FlrSI,
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />Sulllx)
<br />
<br />2. SEX
<br />Mlle
<br />
<br />lB:rnrd
<br />
<br />EVerett
<br />
<br />Peker
<br />
<br />Grarrl Islarrl, N2~ska
<br />7. SOCIAL SECURITY NUMBER
<br />505-1&6136
<br />
<br />~t 16,__1912
<br />
<br />Sa. Pl.-ACE OF DEATH
<br />~:
<br />
<br />o Inpatient
<br />
<br />QII:IEB- ~ Nursing Homa/I.-TC L.J Hospice Facility
<br />
<br />8b. FACILITY-NAME (II not Instltullon, give streel and number)
<br />, Veterans Affairs N::rlical C'.enlP....r
<br />2201 N. :Brca.:1w=>~1
<br />
<br />o ER/Outpallenl
<br />
<br />o Decedent's Home
<br />
<br />ODJl\
<br />
<br />o Olher (Speclly)
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grnrrl Islarrl 68a)3
<br />
<br />Bd. COUNTY OF DEATH
<br />Hill
<br />
<br />9a. RESIDENCE-STATE
<br />
<br />9b. COUNTY
<br />Hmiltcn
<br />
<br />9c. CITY OR TOWN
<br />
<br />lOa. MARITAL STATUS ATTIME OF DEATH 0 Married 0 Never Married
<br />
<br />Mm}t..Ette
<br />...- --.-----..J..-..... .......-
<br />9B. APT. NO
<br />
<br />. --..-.-..--.,,,..,.,,.
<br />lOb. NAME OF SPOUSE (First, Middle, Last, Sulflx)II wite, give maiden name.
<br />
<br />91. ZIP CODE
<br />
<br />68854
<br />
<br />9g. INSIDE CITY LIMITS
<br />L.J YES ~O
<br />
<br />9d. STREET AND NUMBER
<br />
<br />o Married, bul separated :w Widowed L.J Divorced L.J Unknown
<br />
<br />n. FAfHER'S-NAME (FlrSI,
<br />John
<br />
<br />Middle,
<br />
<br />Last,
<br />Baker
<br />
<br />Sullix)
<br />
<br />12. MOTHER'S-NAME (Firal,
<br />Pearl
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />Jenkins
<br />
<br />15. METHOD OF DrSPOSITION
<br />XI Burial 0 Donation
<br />o Cremalion 0 Ento~bment
<br />
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />daughter
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dates 01 service if yes.
<br />
<br />__(~.~~,no,.~_runk)l\my 4/3J/194~/6/1945
<br />
<br />CITY / TOWN
<br />
<br />1 6c. DATE (Mo" Dey, Yr. )
<br />J a ll~~.!: y__ 1 2 , 2 0 0 6
<br />STATE
<br />
<br />16a
<br />
<br />ISb.I.-ICENSE NO.
<br />1071
<br />
<br />o Removal OOlher(Specl,y) Grand Island Ci ty Cemetery
<br />
<br />Grand Island, Nebraska
<br />
<br />17e. FUNERAL HOME NAME AND MAII.-ING ADDRESS (Street, City or Town, Stale)
<br />Funeral Home, 2929 S.
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />PART I. Enlet the chain of events--diseases, injuries. or complications--thal di(eclly caused the dealh. DO NOT enter terminal events such as cardiac arrasl,
<br />respiratory arrest, or vanlflculer fibrilla lion without showing the etiology. DO NOT ABBREVIATE. Enter only one ceuse On a line. Add additionallinas II necessary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onset 10 deelh
<br />
<br />tMM~DIAT~ CAUS~ (Final
<br />disuse or condition resulting
<br />In death)
<br />
<br />SequenUallyIIstcondlUons,If ~~
<br />any, leading tolhe ceuse listed DUE TO OR AS A CONSEQUENCE OF' .
<br />onllnea. I .
<br />Emar the UNDERI.-YING CAUSE
<br />(dlsea.e or Injury that Initiated (c)
<br />lheevenlsresulting in death) DUE TO, ORAS-ACONSEQUENCE OF;
<br />lAST
<br />
<br />(a) CAD, AjrerE.L~~
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />~ Years
<br />
<br />I onsst to death
<br />
<br />I
<br />
<br />I
<br />I Fl:w Years
<br />
<br />I onselto dealh
<br />
<br />I
<br />
<br />I
<br />
<br />I
<br />
<br />onset to death
<br />
<br />(0)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death bul not resulting in the underlying cause given in PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />o YES ~ NO
<br />
<br />o Not pregnant within past year
<br />o Pragnant at time 01 death
<br />[J Nol pregnent, but pregnant within 42 days 01 dealh
<br />o Not pregnant, but pregnant 43 days to 1 year before death
<br />o Unknown if pregnant within the past year
<br />
<br />o AccidenlO Pending Investlgellon
<br />
<br />2 t b.IF TRANSPORTATION INJURY
<br />L.J Drlver/Operetor
<br />
<br />o Passenger
<br />
<br />o Pedestrian
<br />
<br />o Other (Specily)
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />20. IF FEMAI.-E:
<br />
<br />21 a. MANNER OF DEATH
<br />m Natural 0 Homicide
<br />
<br />o YES all NO
<br />
<br />o Suicide 0 Could not be determined
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAII.-ABI.-E TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES U NO
<br />
<br />DYES L.J NO
<br />
<br />
<br />22a. DATE OF INJURY (Mo" Day, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. Pl.-ACE OF INJURY.At home, farm, street, laclory, ofllco building, construction site, elc. (Specify)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />22f.I.-OCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYlrOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />24a. DATE SIGNED (Mo., Dey, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />~
<br />
<br />,..:Hj
<br />.ouz
<br />_<r:
<br />'ll"'o
<br />ji!!i:1=
<br />c.D.. ir.J; ~
<br />EIA(:Z
<br />8f5zo
<br />"z::>
<br />.coo
<br />~a:CJ
<br />o~
<br />'" 0
<br />
<br />m
<br />
<br />24C. PRONOUNCED DEAD (Mo" Dey, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examination and/or Investigation, In my opinion dBath occurred at
<br />lhelime, dale and place and due to the cause(s) staled. (Signa lure and Title) '"
<br />
<br />26.. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />NOI Applicable If 26a is NO 0 YES 0 NO
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />JAN 1 2 2006
<br />
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