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<br />~
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND ftrAfAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL'1lECO/Y1JiN FIL.EW/TH
<br />THE NEBRASKA HEAL.TH AND HUMAN SERVICES SYSTEM, VITAL STAtls;rjijjJ;iiG1ipNF!J!I}ICHIS
<br />
<br />::;::":~::;TORY FOR VITAL RECOROS M2!fr-\R
<br />~;~L~ ;E;2~;KA 20060197 2 H~'II~;~
<br />\~~~:. i';t'f't~~~f"~(f'
<br />._~'.", ::m~ ,;::~' '~, ,,:,';:'~I
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC;~FiNA;;k\tA.~b~;pP..... PO.RT.. 0 6.
<br />CERTIFICATE OF DEATH _ . '.< _u___....__... .n. 215.7. 4
<br />1. DECEDENT'S.NAME (First, Middle, Lest, Sufllx) 2. SEX 3. DATE OF DeATH (Mo., Day, Yr.)
<br />__._._._____'L?)ma.h_...I.L~pe Ba,lL__.....___.___._.____._ ema1e e bruar 15,,_. 2006
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Greeley County, Nebraska
<br />
<br />5a. AGE-Last Birthday
<br />(Yrs.) 7 8
<br />
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />
<br />HJ:~~: _..:~_~_~:r y 22, 1927
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />508-34-1024
<br />
<br />8a. PLACE OF DEATH
<br />!::!QSPITAL:
<br />
<br />00 Inpatient
<br />
<br />QII:JEB: D Nursing Home/LTC D Hospice Facility
<br />
<br />8b. FACILITY"NAM~ (II not InstltUllon, give street and number)
<br />St. Francis Medical Center
<br />
<br />D ER/Outpatient
<br />
<br />D Decedent's Home
<br />
<br />U IX)\ D Other (Specify)
<br />8c. CITY OR TOWN OF D~ATH (Include Zip Code) ad. COUNTY OF DEATH
<br />
<br />
<br />Nebraska
<br />
<br />68803
<br />9b. COUNTY
<br />Hall
<br />
<br />Hall
<br />
<br />Grand Island
<br />9a. R~SIDENC~-STATE
<br />
<br />9d. STRE~T AND NUMBER
<br />
<br />9c. CITY OR TOWN
<br />Grand Island
<br />g-';:-;P;:'.NOjJ" 9fZIPCODE--
<br />68801
<br />- --- -. ".,,-"'.~-,-_..,. -
<br />10b. NAME OF SPOUS~ (First, Middle, Lasl. Sufllx) If wifa, giva maiden name.
<br />
<br />.. .. 'lgg~s~::ciTY~iM~~'
<br />
<br />. _~._.~_~..__.., _.n.'....- .no....__
<br />
<br />821 N. Washi~Bton St.
<br />1 Oa. MARITAl STATUS AT TIM~ OF D~ATH JOt Married D Nover Married
<br />
<br />U Married, but 'epareted U Widowed W Divorced U Unknown
<br />
<br />Calvin Ball
<br />
<br />11. FATHER'S.NAME (First,
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S.NAME (Fitst,
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />
<br />_____----.B a r 1,,____.____ R i c h ~:r_L G i b b y'_e 1 m_l2-J:L ...
<br />
<br />_~~~~:,~ol~~U~.k~ AR.~~ORc~=-~ivedales ot service .lfY~j14a INF~~~~:~~~E i n ~ ~ ~ 1_
<br />15;::~a~OFDI~~:~::I~~ 16a(1lMER-SIGN~T)J3!;J. _ t: ~t~~NO --
<br />
<br />U Cremation D Entombment 16d.CEM'ETERY,'REM'A:rORYO?c:ER lOCATlQN'--~--- CITY / TOWN
<br />
<br />A 1fr~.d.l?:.....t1..~I?_EJ_er sm_ith_
<br />-j14b. RElATIONSHIP TO DECEDENT
<br />Husband
<br />_n ___..u"....."._..... ,."......__._
<br />16c. DATE (Mo., Day, Yr.)
<br />
<br />.. .___ ~.1:E. 2 0'_m?_Q9~
<br />
<br />STATE
<br />
<br />
<br />DRemoval D Other (Specify) West1awn Memorial Park Cemetery, Grand Island, Nebraska
<br />
<br />18. PART I. Enter the .Qh~.f.j1.Ye.ats.--dlseasest injuries, or c:otnpllcations--that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular librlllation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add addilionallin8s If necessary.
<br />
<br />
<br />17,. FUNERAL HOME NAM~ AND MAILING ADDRESS (Streel, City orTown, Slate)
<br />All Faiths Funeral Home,2929 S.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />I
<br />I
<br />
<br />I on,et to dealh
<br />I
<br />I
<br />..1.
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />
<br />i-I~' J-,r')
<br />
<br />IMMEOIATE CAUSE (Final
<br />disease or condition resulting
<br />In death)
<br />
<br />(\ ,
<br />(a)'Jcrtn,>
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />Sequenllally IIsl condlllons,lf
<br />sny,lesdlng 10 the cause listed
<br />on line a.
<br />Enter 'he UNDERlYING CAUSE
<br />(di.eesa or Inlury Ihollnitioled
<br />Iho evenls resulting In death)
<br />LAST
<br />
<br />(b) fu C\ r)\ \,; '\ t t \ \ J \ i .\-;.J
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />;) ~ t{.j u>
<br />
<br />onset to deat~
<br />
<br />(c)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to tho doath but nol rosulllng In the undsrlying cause given In PART L
<br />
<br />()..,~Q'R n~ 'V~ \c,\',\\i(Q..; , \'\'--I.?'j" ~ l\.\(>_fY"'>i~'-'
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />D YES ~O
<br />
<br />i
<br />
<br />,~
<br />
<br />'i!'
<br />....p,
<br />
<br />20)F FEMAlE:
<br />~ Nol pregnant wllhln past year
<br />o Pregnant alllme of death
<br />o Not pregnant, but pregnant within 42 days 01 death
<br />o Nol pregnant, but pregnanl43 days 10 1 year before death
<br />D Unknown if pregnant within Ihe pasl yoe,
<br />
<br />21a. MArw~R OF D~ATH
<br />rn,atural 0 Homicide
<br />
<br />D AccidentD Pending Investlgallon
<br />D Suicide D Could not be determined
<br />
<br />21b.IFTRANSPORTATION INJURY 210. WAS AN AUTOPSY PERFORMED?
<br />D Driver/Operator
<br />
<br />D Passenger
<br />
<br />DYES
<br />
<br />Q11' 0
<br />
<br />o Pedestrian
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABl~TO
<br />COMPLETE CAUS~ OF DEATH?
<br />D Y~S U NO
<br />
<br />U 01her (Specify)
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PlACE OF INJURY.AI home, larm, streel, lactory, office building, conslructlon site, elc. (Spsclfy)
<br />m
<br />
<br />. ,i',' ~ ": 1
<br />
<br />22d INJURY Ai--WOR~? 220 DESCRIBE HOW INJURY OCCURRED
<br />DYES D NO
<br />-----~ - ---- ~"
<br />221. lOCATION OF INJURY. STREET & NUMBER, APT. NO. CITYlfOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Februar ,15
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIM~ OF DEATH
<br />
<br />23b. DAT~ SIGNED (Mo.. Day, Yr.)
<br />reI? ) 4 G '" '--Q
<br />
<br />23d. To the be.t of my knowladge, death occurred _llh_ lime, date and place
<br />and due to tho cause(s) staled. (Signalure end Tille) "
<br />
<br />230. TIME OF DEATH
<br />1: 1 0 P . m
<br />
<br />,,:i 1;;
<br />"'~~
<br />hE
<br />~~ic(~
<br />oiJ:~~
<br />~ L1l::>
<br />"'~o
<br />~a:O
<br />815
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />
<br />m
<br />
<br />24e. On the basis of examination and/or Investigation, In my opinion death occurred al
<br />the lime, date and place and duo to Ihe cause(s) steted. (Signature and Title) "
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />II YES ~O 0 PROBABlY D UNKNOWN D YES ~
<br />27. NAME, TiTlE AND ADDRESS OF CERTIFIER-ipHYSICiAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYj-iTyp.';;ri>ri'nl)
<br />Jennifer King, M.D.,729 N. Custer Ave.,Grand Island,
<br />
<br />28b, WAS CONSENT GRANTED?
<br />
<br />Not Applicable 1128_ Is NO DYES
<br />
<br />~
<br />
<br />Nebraska
<br />
<br />68803
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DAT~ FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />
<br />FEB 2 1 2006
<br />
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