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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 Rlgl;Q/MV;JN FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISJJC$-~t}tJ~-WHICH IS
<br />
<br />:::;::~::::::~TORY FOR VITAL RECORDS. ;6Z:g'=ffi;~
<br />'0":/' fJTMJIJ:~s. tiiP~R
<br />APR () 3 200B 20 O~. 032 9 6 ASslsTANr-ST.4~~REGISrRJtR
<br />LINCOLN, NEBRASKA HEAL TH ANO.H:vMAN$kliViCES
<br />.. =' I."::'':'
<br />
<br />.~
<br />
<br />
<br />STATE OF. NEBRASKA - DEPARTMENT.O.F. HEA.LT. H.. A.. .ND HUM. .AN.. SERVICES F. INANCEANDSUP-PORh '6''- 2.3 A.... 9..' 2.. __._
<br />__ CER"flFI~~TE;_QE....IJ..!;ATH__. .... u_ ...
<br />DECEDENT'S.NAME (First, Middle, Lasl, Suffix) 2, SEX 3, DATE OF DEATH (Mo., Day, Yr.)
<br />Dorothy Drussila Cobb Female March 23, 2006
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH -ora, AGE:La~I.8Irlhday 5~~NDER I.Y.EAR 50, UNDER I DAY 6. DATE OF BIRTH (Mo" Day, Yr,)
<br />(Yrs,) MOS, DAYS HOURS MINS,
<br />65 February 2, 1941
<br />
<br />Ba, PLACE OF DEATH
<br />
<br />, I
<br />\\"j
<br />
<br />500-42-8071
<br />
<br />~:
<br />
<br />o Inpatlont 0Il:JE8:
<br />
<br />o Nursing Horns/LTC U Ho.pica Facillly
<br />
<br />'8b, FACILITY-NAME (If not Inslllullon, glvs slreot and nllmbar)
<br />
<br />.. ER/Oulpallenl
<br />
<br />o Decadent's Home
<br />
<br />St. Francis Medical Center
<br />
<br />DOC>\
<br />
<br />o Olhor (Spacily)".__..
<br />
<br />8c. CITY OR TOWN OF DEATH (Includa Zip Coda)
<br />
<br />Grand Island 68803
<br />
<br />8d, COUNTY OF DEATH
<br />Hall
<br />
<br />9a, RESIDENCE-STATE
<br />Nebraska
<br />
<br />Bb. COUNTY
<br />Hall
<br />
<br />
<br />9d. STREET AND NUMBER 91. ZIP CODE
<br />1213 N Boggs Ave. 68803
<br />._...._ ,_""~~.__~_.~'V.
<br />lOa. MARITAL STATUS AT TIME OF DEATH l&.Marriad 0 Navar Marriad lOb. NAME OF SPOUSE (First, Middle, Lasl, Sulllx) If wile, give melden nama.
<br />
<br />9g, INSIDE CITY LIMITS
<br />
<br />. YES 0 NO
<br />
<br />U Married, bUlseparaled U Widowed 0 Divorcad 0 Unknown
<br />
<br />Darrel D. Cobb
<br />
<br />, 1. FATHER'S-NAME (Firsl, Middle,
<br />Bernhardt (NMI) Heyer
<br />
<br />LaSI,
<br />
<br />Suffix)
<br />
<br />12, MOTHER'S-NAME (FirSI,
<br />Regina C. Smith
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />
<br />o Burl.1
<br />
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />
<br />13, EVER IN U,S, ARMED FORCES? Give date. of .arvie. it ya..
<br />(Yos, no, or link.) NO
<br />15. METHOD OF DISPOSITION
<br />
<br />~
<br />
<br />
<br />160, DATE (Mo" D.y, Yr. )
<br />March 26, 2006
<br />
<br />~ Cremation 0 Entombment
<br />
<br />CITY / TOWN
<br />
<br />STATE
<br />
<br />o Removal DOlher(Specily) Central Nebraska Cremation Serv:i.ce, Gibbon, Nebraska
<br />
<br />17., FUNERAL HOME NAME AND MAILING ADDRESS (Streef, Cify or Town, Slale)
<br />Kleine Funeral Home, 3213 W North Front St., Grand Island, NE
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />
<br />~~s~:~~~;;O~:~I~~::~nU~:lng -.~~E TO~~~ C~~~E~~ O~ \
<br />
<br />In d..lh)
<br />
<br />onset 10 dealh
<br />
<br />-:ui'Of C-- ~.. .Q A
<br />--- -. ... -...-
<br />
<br />o
<br />
<br />onsello de'lh
<br />
<br />
<br />Sequentl.lly 11.1 conditions, If (b) ._...CD.roC\.O 1\..1I Ar~.. :I:K.~<S(. ;-051_
<br />any, faadlng 10 tho COliS. listed DUE TO, OR AS A CONSEQUENCE illF:
<br />on linea. ,
<br />Ente,the UNDERLYING CAUSE ,_, ^ \ I _ \ .
<br />(dlsaasoorlnjllrythollnitl.led ~ ~ c. .t:CJG ~ \ ~
<br />Ihe evenls resulting In de.lh) DUE TO,-OR AS ii"C.ONSEQUENCE OF:
<br />lASf
<br />
<br />_________(d) \~O er<:2.,'0c \ n ~ -kn l -€OJJ...~_
<br />18, PART II. OTHER SIGNIFICANT CONDlTIONS-C\;,t\;ons contrlbufing 10 fhe dealh bUI nol resulting In Ihe UljderlY'1g eau.e ~von In PART I.
<br />CQ.("Q.6ruvQ.sc...u\Q r i,,\~~'~C'!I1\ QQrchti s.~no~,~
<br />_kd_.?~c.\ V lo ~
<br />20. IF FEMALE, 21.. MANNER OF .DEATH
<br />~I- U flomieida
<br />
<br />on~9h~L
<br />
<br />o~ttSafh~-.
<br />
<br />
<br />SO wCS__
<br />
<br />19, WAS MEDICAL EXA~INER .
<br />OR CORONER CONTACTED?
<br />
<br />DYES e-mi
<br />
<br />B'1foIpregnanl wilhln p"1 year
<br />U pregn.nl al time 01 dealh
<br />o Nol pregnanl, bUI pregnant within 42 day. 01 dealh
<br />o Not pregnanl, bul pragnant 43 days 10 I year belore desth
<br />U Unknown II pregnant whhln Iha past y..r
<br />
<br />o AccidenlD Pending Inveslig.tlon
<br />
<br />21b, IF TRANSPORTATION INJURY 210, WAS AN AUTOPSY PERFORMED?
<br />o Drlver/Operalor
<br />
<br />U p.s.engar
<br />
<br />DYES
<br />
<br />~
<br />
<br />o Suicide 0 Could nol be delermlned
<br />
<br />o Pedestrian
<br />o Othor (Speclly)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />U YES 0 NO
<br />
<br />DYES 0 NO
<br />
<br />
<br />220", PLACE OF INJURY-At homa,larm, slroot, factory, ofllce bUilding, con.truotlon-s~e, ole. (Specify).
<br />
<br />22a, [JATEOFINJURY (Mo" Day, Yr.)
<br />
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />221, LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITY/fOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />
<br />z
<br />~~
<br />.,,!.]
<br />tl~
<br />1i::E::J
<br />Ea.z
<br />8 goo
<br />1S.1:S
<br />.cc
<br />~~
<br />-0:
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />-.3 d4- - ..~..
<br />23b. DATE SIGNED (Mo" Day, Yr,)
<br />'z, - d., io ... G
<br />
<br />24a, DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />
<br />... _..8...~I/,.J1=[)
<br />23c. TIME OF DE": H
<br />'055"1 m
<br />
<br />... :l 1:;
<br />,cuZ
<br />llii5~
<br />,,~l:
<br />I3..D..o:(::;
<br />E." >- Z
<br />8ffi~o
<br />..z:;'
<br />.coo
<br />~a:u
<br />OL
<br />uo
<br />
<br />m
<br />
<br />240. PRONOUNCED DEAD (Mo., Day, Yr.) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examination and/or Invesllgalion, In my opinion dRath occurred at
<br />Iho!ima, dalo and place and duelo Ihe oau.a(s) slalod. (Signalure and Tille)"
<br />
<br />25. DID TOBACCO USE CONTRI UTETOTHE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />~U NO PROBABLY 0 UNKNOWN ~ ~
<br />
<br />27:NAME, TITLE AWJ ADDfl.[SS OF CERTIFIER-ipi'wSI<t!AN-,GOROll~'~ Pl:!YSICIAN OR COUNTY ATTORNEY) (Ty'p'- or Prin))'-
<br />Larry L. Hans9n, M.D., l~lb W Faidley Ave.,Grand
<br />
<br />26b. WAS CONSENT GRANTED?
<br />Not Applieabla if 26a.is NO....~S 0 NO
<br />
<br />Island NE 68803
<br />
<br />29.. REGISTRAR'S SIGNATURE
<br />
<br />
<br />29b. DATE FILED BY REGISTRAR (Mo" Day, Yr,)
<br />
<br />MAR 3 1 2006
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