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<br />DATE OF ISSUANCE
<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 REG11R1'HJN FiLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISr.a*Tloii--WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS ~c \"'oc - - ':"':=':}"'-'=;'o' -,-o~-,-
<br />
<br />. -- .. if ~._.--
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<br />-~ -." --- ~'---
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<br />{-c/ -::~~~t ~ cd;,~~
<br />
<br />ASSIST4NT.SlATE'RE6IstFiAiJ
<br />HEA't.TH AND/iUMANSE!fviCES
<br />:_: --;'-'~~~.i.,~~~::7~. '-".--,::'~ ,:.:: .
<br />~ ":', .-.: - -:-:...:.
<br />
<br />200602135
<br />
<br />JUN 1 6 2005
<br />LINCOLN, NEBRASKA
<br />
<br />1. DECEDENT'S-NAME
<br />
<br />-"""- - --
<br />: ~ ~~~~~~""~; ~ ,:~'l;~)~~~~:
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND supitiRr-=- 5' n 6 7 A '9
<br />___ __ _. __ _ CERTIFICATE 9F DEATH _ _ 0 ----U _ _ ~_
<br />(Flrsl, Middle, Lost, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Alice Barbara F<l.~!:Q.~ks Female June 5, 290_5
<br />
<br />f)
<br />.\,~
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Wood River, Nebraska
<br />
<br />5a. AGE-Last Birthday
<br />(Y".) 83
<br />
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />5. DATE OF BIRTH (Mo.. Day, Yr.)
<br />
<br />November 29, 1921
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />505-22-3579
<br />
<br />Ba. PLACE OF DEATH
<br />lillSl'lIAl.: IlQ I n pat lent
<br />
<br />QiliE'!: 0 Nursing Homo/LTC 0 HO'pice "ocllily
<br />
<br />FACILlTY.NAME (If nol In,tilution, give slraat and number)
<br />St. Francis Medical Center
<br />
<br />o ERIOutpatlent
<br />
<br />o Decedent's Home
<br />
<br />9.. RESIDENCE-STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />3119 W. Faidley
<br />lOa. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Marriod
<br />
<br />L---
<br />9b. COUNTY
<br />___..w Hall
<br />
<br />U L'O'I OOth.r(SpeclfYL_
<br />
<br />u'-~_~FD~:il
<br />
<br />re. CITY OR TOWN
<br />
<br />__ Grl'.d ~~.land
<br />ge. APT. NO 91. ZIP CODE
<br />68803
<br />.' ',' ",., --.
<br />lOb. NAME OF SPOUSE (First, Middlo, Last, Suffix) If wifo, 9ivo maiden name.
<br />
<br />9g. INSIDE CITY LIMITS
<br />Xl YES LJ NO
<br />
<br />8c, CITY OR TOWN OF DEATH (Include lip Code)
<br />Grand Island
<br />
<br />o Married, bUI .eparated ~ Widowed 0 Divorced LJ Unknown
<br />
<br />Murice Fairbanks
<br />
<br />(Dec. )
<br />
<br />11. FATHER'S.NAME (Firsl,
<br />Earl
<br />
<br />Middle,
<br />
<br />Lasl,
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S.NAME (First,
<br />Johannah
<br />
<br />Middle, Maiden Surneme)
<br />A. Huebner
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15c. DATE (Mo., Dey, Yr.)
<br />June 8. 2005
<br />
<br />Clark
<br />13. EVER iN U.S. ARMED FORCES? Give datos of service If yes. Ilia INFORMANT-NAME -
<br />No Kay Bockstadter
<br />
<br />16aEMB ~~ L./ ----l:_LZtVt7
<br />
<br />IBd CEMETERY, CREMA~~!cATION CITY /TOWN
<br />
<br />R.
<br />
<br />15. METHOD OF DISPOSITION
<br />iXBurlal 0 Donation
<br />
<br />o Cremallon
<br />
<br />U Entombment
<br />
<br />STATE
<br />
<br />o Removal 0 other (Spocify)
<br />
<br />Shelton Cemetery
<br />
<br />Shelton,
<br />
<br />Nebraska
<br />
<br />170. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City orTown, Slato)
<br />Apfel Funeral Home,
<br />
<br />
<br />Zip Code
<br />
<br />PART l. Enter lhe chain of event.~:-dlseases, InJuries, or complications--Ihat dIrectly caused the death. DO NOT enter terminal events suoh as cardiac arras!,
<br />respiralory arrest, or ventrIcular fIbrillation wllhoUI showing lhe etiology. DO NOT ABBREVIATE, Enter only one cause on a line. Add addlUonalllnes If necessary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />Sequentially list conditions! if
<br />any, leodlng to the cau.ellsled nOUE TO, OR AS A CONSEQUENCE: OF:
<br />on line e.
<br />Entorlho UNDERLYING CAUSE
<br />(dlsea.e or Injury Ihal Inltlatod (c)
<br />the evenls ,e.ulllng In death)
<br />lAST
<br />
<br />IMMEDIATE CAUSE'
<br />
<br />~ . ~e p s;,1..s - ,.J2- i \ il /0 '\ r..f- V'c-J " cP f?v1 ~kL--
<br />:~ETO~7:;d;~p}tW~(L- '1; Sf}7~
<br />
<br />onset to death
<br />
<br />IMMEDIATE CAUSE (Flnol
<br />dl!i@aSeDfconditlonresultlng
<br />In death)
<br />
<br />0lU' ~
<br />
<br />onsello deelh
<br />
<br />U r'\!41oc.tJ-vL.,
<br />
<br />onset 10 dealh
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />.L.... ___
<br />I onset to doalh
<br />I
<br />I
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Conditions conlributlng to tho deolh bul nol resulllng In tho underlying caus. given in PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />~-
<br />
<br />20. IF FEMALE:
<br />}l( Not pre9nanl wllhln pasl yeor
<br />o Pregnanl al lime of deeth
<br />o Not pregnsnt, but pregnanl wilhin 42 deys 01 death
<br />U Nol pregnanl, but pregnant 43 deys 10 I year before death
<br />o Unknown If pregnant within tho past year
<br />
<br />21a~NNER OF DEATH
<br />..ll.l Notural U Homlcida
<br />
<br />o YES ,>If! NO
<br />
<br />21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />o AccidentO Pending Invesligatlon
<br />
<br />U Passenger
<br />o Podestrlan
<br />U Other (Spocify)
<br />
<br />o YES
<br />
<br />)S'(N 0
<br />
<br />U Suicide 0 Could not be determlnad
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />o YES
<br />
<br />UNO
<br />
<br />22a. DATE OF INJURY (Mo.. Day, Yr.)
<br />
<br />22b, TIME OF INJURY 22c. PLACE OF INJURY.AI home, farm, strael, lactory, office building, conslruction slta, ele. (Specify)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />
<br />o YES 0 NO
<br />
<br />221. LOCATION OF INJURY" STREET & NUMBER, APT. NO.
<br />
<br />CITYfTOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo.. Day, Yr.)
<br />
<br />U~?-tJ5""
<br />
<br />23b. DATE SIGNED ~o, Day, Yr.)
<br />l.D-q- m
<br />
<br />23d. To the bost 01 my knowledge, doalh occurred eltha time, dato and place
<br />and d~Se(S) slated. (Slgnalure an;;;;[3'
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr,)
<br />
<br />24b. TIME OF DEATH
<br />
<br />
<br />:iili
<br />~- ;Z
<br />""1ij0:
<br />1!>~
<br />!~~~
<br />E.w ~ Z
<br />00: 0
<br />Uw
<br />1lZ:>
<br />00
<br />~a:(J
<br />o ~
<br />uo
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo.. Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />249. On the basis of examination and/or Invesllgation, in my opInion death occurred at
<br />Ihe time, dale and place and due 10 tho cause(s) 5Ialed. (Signature and Tille) T
<br />
<br />2Ba. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 2Bb. WAS CONSENT GRANTED?
<br />
<br />U YES ~NO U PROBABLY 0 UNKNOWN ." 0 YES . ~O Not Applicable If 28e Is NO O.YES i:li:f NO
<br />27. NAME, TITLEA'NP ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) -(Typ'-or Print)
<br />Richard Fruehling M.D. 2116 W. F idley Ave., Grand Island, NE 68803
<br />
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />~i
<br />
<br />JUN 15 2005
<br />
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