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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SEflVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECQ8Q ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT[~~EVYHICH IS
<br />
<br />:::;:::~::::~TORY FOR VITAL RECORDS. -;~j,:2~ii:f~
<br />
<br />~-7"",7iTANLEY S:#;(iPER
<br />OCT 0 6' 2005 2 0 0 6 0 3 7 7 7 ASSISTANt STATE IjE(1lSiRAR
<br />LINCOLN, NEBRASKA HEALTfI AND HUMAN f!ERVlCES
<br />
<br />". ~,,_.~ ._,-
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<br />._ :.:. - ==,.J~';
<br />
<br />.Ao. ' ._ .::=.-:. ~ ..: -. :;.~
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<br />
<br />'.
<br />
<br />
<br />f
<br />
<br />1. DECEDENT'S.NAME (Flrsl, Middle, Lael,
<br />
<br />Kenn~th Weune _N~ewb.r'ey
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Last Blrlhday
<br />(Yrs.)
<br />
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES f'INANQE-ANDSOPPORT 05 1,0. 9 3 6
<br />CERTIFICATE qF DEATI:i ... . '_~___
<br />
<br />Sulflx)
<br />
<br />2. SEX
<br />Male
<br />
<br />3. DATE OF DEATH (Mo., Da6YL)
<br />Sept. 22,2 05
<br />
<br />Cozad,
<br />
<br />Nebraska
<br />
<br />60
<br />
<br />5b. UNDER I YEAR
<br />-~IIY-S
<br />
<br />I
<br />
<br />50. UNDER t DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo" Day, Yr.)
<br />
<br />April
<br />
<br />29,
<br />
<br />1945
<br />
<br />W.
<br />
<br />9th St.
<br />
<br />I
<br />-1- .. ea'PL.AcEOFDEATH
<br />
<br />IiQSEJ1AL.
<br />
<br />
<br />
<br />
<br />,. .- "-
<br />
<br />CJ Inpallenl
<br />
<br />QlliEB;
<br />
<br />CJ NurSlng Home/LTC CJ Hospice Facility
<br />
<br />8b. FACILlTY.NAME (If nol Inslltution, glva slreel and numbar)
<br />
<br />CJ ER/Oulpallent
<br />
<br />r1 Decedent's Home
<br />
<br />CJroI
<br />
<br />CJ Olhar (Specify)
<br />
<br />8c, CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island
<br />
<br />8d. COUNTY OF DEATH
<br />Hall
<br />
<br />---- - . _J9b:-cH~~_1 ~1;:~O;t Island
<br />.~~_______ --.. -~()- 91618c8DO 1
<br />
<br />
<br />Q ,~, """J ,~, ""'0> '"'"" 1'''', ."" , "", '"""I """, ,~ ~"'" W~,
<br />
<br />- Clara Ruth Brown
<br />o Married, but separated LJ Widowed 0 Divorced 0 Unknown
<br />
<br />,~---,--,-- ---~ -
<br />Middle, Lasl, Suffix) 12. MOTHER'S.NAME (FlrSI,
<br />
<br />68801
<br />
<br />-=ri INSIDE CITY LIMITS
<br />
<br />XI YES CJ NO
<br />." --- "-''''--
<br />
<br />1 1. FATHER'S-NAME (Firsl,
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />
<br />Fred
<br />
<br />
<br />y---
<br />14a, INFORMANT-NAME
<br />Clara Ruth Neybrey
<br />
<br />J1argaret
<br />
<br />Allen
<br />
<br />13. EVER IN U.S, ARMED FORCES? Give daleS of service il yes,
<br />(Yes, no, or unk,) No
<br />15, METHOD OF DISPOSITION
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />18a
<br />
<br />LJl7l21t4~~
<br />16d CEMETERY, CREMATORY OR OTH~~~
<br />Central Nebraska Cremation
<br />
<br />16b. LICENSE NO,
<br />1071
<br />
<br />18c. DATE (Mo., Day, Yr. )
<br />Sept. 26, 2005
<br />
<br />o Burial
<br />
<br />CJ Donation
<br />
<br />:t} Cremation
<br />
<br />o Entombment
<br />
<br />CITY /TOWN
<br />SErvice Gibbon,
<br />
<br />STATE
<br />Nebraska
<br />
<br />U Ramoval
<br />
<br />CJ Other (SpeCify)
<br />
<br />..-..--.- -
<br />_ Ua...El!.blE.P1\LHD~1E.H.AJ.J1t.ANO ~AJ'd!_.w.G..A!:lDB.ESS_ ~Clt:,:.:.:.+~, c:l~-.i':
<br />
<br />PART I. Enter Ihe c;..hain of events--diseases, injuries, or complicalionsnthat directly caused the death. DO NOT enter terminal events suoh as cardiac arrest,
<br />respiralory arreS!, or venlricular fibrillation withoul showing Iha etiology. DO NOT ABBREVIATE. Enter only one Cause on a line. Add addltlonallln.s if necessary,
<br />IMMEDIATE CAUSE:
<br />
<br />Onset to death
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In death)
<br />
<br />w Acute Emphysema
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />1 year
<br />
<br />on'ello daalh
<br />
<br />Sequentlatly list condiUons, if (b)
<br />any, le.dlng lothe causollsled DUE TO, OR IISA CONSEQUE;;iCE -OF:
<br />on line 8.
<br />Enlarlhe UNDERLYING CAUSE
<br />(diseaaa or injury IhallnlUaled (c)
<br />Ihe evenls resulting In de.th)
<br />lAST
<br />
<br />onsello death
<br />
<br />I onsello dealh
<br />I
<br />~ I
<br />
<br />18 PART II OTHER SIGNIFICANT-CONDiTlONS-Condlllon,contrlbullng 10 Ihe dealh but nol rasu",ng I~ Ih~ underlying Causa glv~n In PAR=rTt9-WAS MEDICAL EXAMINER-
<br />OR CORONER CONTACTED?
<br />Il!I YES CJ NO
<br />
<br />20 IF FEMALE - -1110. MANNER OF DEATH - -" 21b.IFTRA~SPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />CJ Nol pregnanl wllhln pa,1 year I.ll.Nalural CJ HomiCide CJ Driver/Operator CJ YES ~ NO
<br />
<br />Q Pregnant at lime 01 death U AccldentO Pending InvestigatIon 0 Passenger
<br />CJ Pedestrian
<br />CJ Not pregnanl, bul pregnant wilhln 42 days 01 dealh 0 SUICide U Could nol ba determined 21d. WERE AUTOPSY FINDINGS AVAiLABLE TO
<br />CJ Nol pregnant, bul pregnanl43 days 10 1 year balore dealh U Other (Specity) COMPLETE CAUSE OF DEATH?
<br />___u Unknown II pregnant WllI1ln tile lJast year I J _ _ _ _ _ U YES .Y~NO
<br />
<br />22e DATE OF INJ~RY :MO, Day, Yr) j 22b. TIME OF INJUR: ]22C PLACE OF INJURY.At home, 'a,,;;: Sl;ee:, laclory, ofllce bUilding, c~nstructl~n srla, etc. (SPeCilyj-
<br />
<br />
<br />22d.INJURY AT WORK? 22e, DESCRIBE HOW INJURY OCCURRED
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />CJ YES U NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr,)
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr.) 24b. TIME OF DEATH
<br />Septe~~_er 26, 200~ Approx. 6 :OOa m
<br />
<br />m
<br />
<br />:)'B:j
<br />.cuz
<br />jU
<br />c.o..;.s,: ~
<br />~~~~
<br />"z=>
<br />.coo
<br />~a::O
<br />o~
<br />(Jo
<br />
<br />24c, PRONOUNCED DEAD (Mo" Day, Yr.)
<br />Se tember 22, 2005
<br />
<br />24d. TIME PRONOUNCED DEAD
<br />8:15a m
<br />
<br />23b, DATE SIGNED (Mo" Day, Yr.)
<br />
<br />23c. TIME OF DEATH
<br />
<br />~
<br />
<br />23d. To lhe best of my knowledge, death occurred atlhe time, date and place
<br />end duelo Ihe cause(s) ,taled. (Signalure and Tille) T
<br />
<br />24e, On the basis of examination and/or Investigation, in my opinion death occurred at
<br />the lime, dale and place and due 10 Ihe cause(s) staled, (Signalur. and Tille) T
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />26a. HAS ORGAN OR TISSUE DONAT
<br />
<br />
<br />rj YES U NO CJ PROBA8LY 0 UNKNOWN CJ YES tfNO Nol Applicable If 26a is NO U YES CJ NO
<br />27:-NAME,'iiTLE AND ADDRESS~OF CERTIFIER (PHYSICIAN, CORONER'S PHYSiCIAN OR COUNTY ATTORNEY) (l'!p. or Print) - 131 So u th L O-C-U 5 t S tree t
<br />E. G. Edwards, Sergeant Grand Island Po ice Department Grand Island, NE 68801
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b, DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />Se tember 29 2005
<br />
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