|
<br />.
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBR.f.SKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECO.JW..:!J!!lElLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTlC$';S"tj;I.JfJKWtllCH IS
<br />
<br />
<br />:;;p~:i:~7irroRY FOR YFr'L RECORDS ~1~~1
<br />
<br />As'sJS'TANtsiATER~GlSiR-Aii:'/;
<br />LINCOLN, NEBRASKA 2 0 0 6023 'i 3 HEA~r.fi~D1;IflMAl!.;~E1JVtCAf'
<br />~~~ . ~,. <~:~?~;~.!:'-<~~- ,,<.~~~::
<br />.-i~,~~~~~_~.~~ ~7:~,~:r-~~'~',~~~~-
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND StJPPO~',- ""'0' "-5- 0 4 3 2 3
<br />CERTIFICATE OF DEATH ...._..._n_
<br />
<br />--'
<br />
<br />j
<br />
<br />
<br />DECEDENT'S-NAME (First,
<br />Edgar
<br />
<br />Middle,
<br />LeRoy
<br />
<br />Le,t,
<br />Gifford
<br />
<br />Sulllx)
<br />
<br />2.SEX
<br />Male
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a. AGE.Lasl Birthday
<br />(Yre,)
<br />
<br />5b, UNDER 1 YEAR
<br />MOS, DAYS
<br />
<br />50, UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />3. DATE OF DEATH (Mo" Day, Yr,)
<br />_April 12, 2005
<br />
<br />6, DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />Kearney,
<br />7. SOCIAL SECURITY NUMBER
<br />508 10 1041
<br />
<br />Nebraska
<br />508-40-1051
<br />
<br />68
<br />
<br />March 27, 1937
<br />
<br />S.. PLACE OF DEATH
<br />J::I.Q.SflIAJ.: 0 Inpallent
<br />
<br />QMB: Xl Nursing Home/LTC 0 Hosploe Feolllty
<br />
<br />FACILITY-NAME (If not institution, give street and number)
<br />
<br />U E;R/Outpatient
<br />
<br />o Decedent's Home
<br />
<br />Central City Care Center
<br />Bc. CITY OR TOWN OF DEATH (Inolude Zip Code)
<br />Central City, 68826
<br />
<br />U COlI 0 Other (Spaolly)
<br />
<br />Bd. COUNTY OF DEATH
<br />
<br />Merrick
<br />
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />
<br />9b, COUNTY
<br />Hall
<br />
<br />90. CITY OR TOWN
<br />Grand Island
<br />
<br />9d, STREET AND NUMBER
<br />419 Holcomb Street
<br />
<br />w~-- MARITAL STATus AT TIME OF DEATH ~Marrlad 0 Never Married
<br />
<br />90. APT. NO
<br />
<br />9t, ZIP CODE
<br />68801
<br />
<br />9g.INSIDE CITY LIMITS
<br />
<br />~ YES U NO
<br />
<br />lOb, NAME OF SPOUSE (First. Middle, Last, Suffix) II wllo, givo meiden name,
<br />
<br />o Married, bul 'eparatod U Wldowod LJ Dlvorcod 0 Unknown
<br />
<br />Kathleen Collins
<br />
<br />11, FATHER'S.NAME; (First,
<br />George
<br />
<br />Mlddlo,
<br />L.
<br />
<br />Last,
<br />Gifford
<br />
<br />Sulflx)
<br />
<br />12. MOTHE;R'S.NAME (Flrsl,
<br />Millie
<br />
<br />MlddlO,
<br />
<br />Malden Surname)
<br />Tobler
<br />
<br />13, EVER IN U,S, ARMED FORCES? Give dalos 01 ,orvlco it yos. 14a.INFORMANT.NAME
<br />(Yo.,nO,OrUnk)YeS 1954-1962 Kathleen
<br />-_._,._-------'''---~,.
<br />15, METHOD OF DISPOSITION 16.. EMBALMER.SIGNATURE
<br />
<br />Gifford
<br />
<br />14b. RE;LATIONSHIP TO DE;CEDENT
<br />,Wife
<br />
<br />16b, LICENSE NO
<br />
<br />16c. DATE (Mo" Day, Yr,)
<br />April 13, 2005
<br />
<br />o Burlol
<br />
<br />o Donallon
<br />
<br />Not Embalmed
<br />
<br />JtJ Crametion 0 Entombmenl
<br />
<br />16d. CE;ME;TE;RY, CRE;MATORY OR OTHER LOCATION
<br />
<br />CITY / TOWN
<br />
<br />STATE
<br />
<br />o ABmoval
<br />
<br />o Othar (Speoify)
<br />
<br />Central
<br />
<br />Nebraska Cremation Service
<br />
<br />Gibbon
<br />
<br />Nebraska
<br />
<br />PART I. Enlor the ~M.iJl..!!lli~--dl'ess.., Injuries. or oomplleallon'--thal dlroctly caused tho doalh, DO NOT ontor lormhalevents ,uoh ss oerdlac a"esl,
<br />respiratory arras!, or ventricular Ilbrlllallon without showIng the etiology. DO NOT ABBREVIATE. Enter only one cause on B. line. Add addlllonalllneslf necessary.
<br />
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Str.et, City orTown, Stato)
<br />All Faiths Funeral Home, 2929 S. Locust st., Grand Island, Nebraska
<br />
<br />IMMEDIATE CAUSE (Final
<br />dlseasB or condition f8sultlng
<br />In deeth)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />(a) jllz b el'~er~ U..e rnev1;6,~
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />onsello deeth
<br />
<br />onsot to death
<br />
<br />Sequentlelly list condlllon., II
<br />any, leading to the cause IIsled
<br />on line ..
<br />Ent.r tho UNDERLYING CAUSE
<br />(dl..... or Inlury th.llnltlaled
<br />the events resulllng In de.th)
<br />lAST
<br />
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE; OF:
<br />
<br />onset to death
<br />
<br />(e)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to deelh
<br />
<br />(d)
<br />
<br />18, PART II. OTHER SIGNIFICANT CONDITIONS.Condltlons oontrlbullng to the death bUI not re,ultlng In the underlying cau", glvon in PART I.
<br />.rDD>>1, tfTIV) 1I-y>er/'IM~"",,'^--
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />o YES II NO
<br />
<br />o AccldentO Pending Invesllgetlon
<br />o Sulolde 0 Could not be dotermlned
<br />
<br />21b, IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />U Passenger
<br />
<br />DYES
<br />
<br />)jfNO
<br />
<br />20. IF FEMALE:
<br />o Not pregnant within past yoar
<br />o Pregnant at time 01 death
<br />o Nol pragnant, but pregnanl wllhln 42 days 01 doath
<br />o Not pregnant, bUI pregnanl43 days to 1 year beforo doath
<br />o Unknown if pregnant within the past year
<br />
<br />21a. MANNER OF DEATH
<br />lI(Natural 0 Homlolde
<br />
<br />o Pedestrlen
<br />o Otnor (Spoclly)
<br />
<br />21d, W~R~ AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLE;TE; CAUSE OF DEATH?
<br />DYES U NO
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />22b, TIME OF INJURY 22e. PLACE; OF INJURY.At homo, larm, ,"eet, laclory, oflleo building, construCtion ,lte, elo, (Speolty)
<br />
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />220. DE;SCRIBE HOW INJURY OCCURRED
<br />
<br />DYES 01( NO
<br />
<br />221. LOCATION OF INJURY . STR~ET & NUMBE;R, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr,)
<br />April 12,
<br />
<br />24a, DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />230. TIME OF DEATH
<br />2: 06 a m
<br />
<br />~~~
<br />llUill:
<br />H~
<br />a.Q..C(~
<br />~ffi~~
<br />1!Z=>
<br />00
<br />~a:O
<br />815
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mn., Day. Yr.) 24d. TIME PRONOUNCE;D DE;AD
<br />m
<br />
<br />24e. On the bis'ls of examination and/or Investigation, In my opinion death occurred at
<br />the tlmo, dato and plaoo and due to Ihe ceu'e(s) statod. (Slgnaluro and Tllla)"
<br />
<br />25, DID TOBACCO USE CONTRIBUTE; TO THE DE;ATH?
<br />
<br />2Be, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b, WAS CONSENT GRANTED?
<br />Not Applicable II 2_Ba IsNO 0 YES J2!( NO
<br />
<br />DYES ]!l. NO LJ PROBABLY 0 UNKNOWN aYES 0 NO
<br />-"-:;:;' NAME, TITL'E-AND'ADDRESS OF CERTIFIER (PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (TYpe or Printi.
<br />Dr. Steven Mahnke MD., 2510 18 Avenue, Central
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />Cit
<br />
<br />Nebraska 68826
<br />
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />APR 1
<br />
<br />
|