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<br />STATE OF NEBRASKA
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<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 fffiCO~E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSJ'fCS-SEC1"/DM;=.'(!l1!liH IS
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<br />:~::::::::;TORY FOR WTAL RECORDS ~l~~~
<br />MAR ?, 4 200R 2 0 0 6 0 3 8 8 0 ASSISTANT STATE REGiSTRAR
<br />LINCOLN, NEBRASKA HEA"t.,tH ArJO._flUMAN SERVICES
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<br />..STATE..O FN.E. BRASKA-DE.. PARTMENTOF HEALTH AND HUM. ANSE. RV.ICE..S-.'ANANCEAND.._...SUPP.ORT06 2. 2588.
<br />---~--______~ERTIFICATE OF DEAT--'='-- ........- _ _ _'------'----___
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<br />1. DECEDENT'S.NAME (FlrSI, Middle, La,l, sumx) 2 SEX ~3 DATE OF DEATH (Mo, Day, Yr)
<br />Edna Lorna Fore Female March 10, 2006
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<br />--4. . CITY-AND S;ATE ORT~RRITORY, OR FOREIGNCOUNTRY. ..0 F BIR..IrH1 '" ;. """"'''''''l." . UND..E R 1 YEAH-50 UNDER 1 DAY 6. DATE OF BIRTH (Mo, Day~
<br />~land~~braska_~~s~~_ MOSI: HOURS MINS. Marc~2~9~
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<br />7. SOCIAL SECURITY NUMBER jBa_ PLACE OF DEATH
<br />--- 50~-16-124~____~_____ 1::lQSf.lIAl.: ilillnpallanl Q.J1IEB: 0 Nursing Homa/LTC OHospiceFscllity
<br />8b_ FACILITY.NAME (If not institution,. give slreat and number) LJ ER/Oulpallent 0 Decedent's Home
<br />St. Francis Medical Center
<br />o IXl'. Q Other(Specily)______
<br />6c. CITY OR TOWN OF DEATH (Include Zip Code) - 18d~UNTY OF DEAi:i:j--- --_
<br />Grand Island 68803 ~ Hall
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<br />9aRES::~:S~A:~a ==rOU;all -=- -~-CI~~R:~:; Islan;-- - - ----
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<br />9d STREET AND NUM8ER -~~ APT. NO 9f ZIP CODE .-- I gg INSIDE CITY LIMITS
<br />2109 N. Huston J_ 68803 XI YES lJ NO
<br />lOa MARITAL STATlJS ATTIME OF DEATHcrMa",ed 0 Never Me"'Jd lOb NAMEOFSPOUSE (First, Middle, Last, SUffIX) II wife, give mslde~ name. - -- -.
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<br />o Married, but ,eparated 0 Wldowad Q Divorced 0 Unknown Daniel Fore
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<br />11. FATHER'S-NAME (First, Middle, - ~t, ----g;;;'lx) t2- MOTHER'S-NAME(Flr~ - M~-----::-- -----;:;;d'en Surnam~
<br />Frank Fitzke Bertha Stimbert
<br />~ER IN U S.-ARMED FORCES? G,ve dates o'-serv,cell yes 14a INFORMANT-NA;.:;;-----..-----jI4b RELATIONSHIP TO D'ECEDENT
<br />(Yes,no,OrUnk)Yes: 5/17/1943 11/6/l9_~_----E..aniel Fo~ ___ __ __ Husband__
<br />IS METHOD OF DISPOSITION 16a EMBALMER- ~N TURE '1 ./ /16b LICENSE NO 16c DATE (Mo, Day, Yr)
<br />~Burlal o Donation _ _ ~__----./.2 Y~__~rch 1~ ?006
<br />o Cremat,on IJ Entombment 16d CEMETERY, CREMATORY 0 0 ER LOCATION CITY / TOWN STATE
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<br />o Removal Q Other (Specify)
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<br />Westlawn Memorial Park Cemetery,
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<br />Grand Island. Nebraska
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<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City orTown, State)
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<br />Apfel Funeral Home, 1123 West Second,
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<br />-"-"'-".-.'-'.-'.-"'.
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<br />-.--...-.--.----.,.,
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<br />Sequenllefly 1101 condlllon" if (b)
<br />any, t.adlng tolhe cause listed --.[;UE TO, 6R AS A CONSEQUENCE OF:-.------::;
<br />on linea.
<br />Enter the UNDERLYING CAUSE
<br />(dlseese Or Injury thst Initiated (c)
<br />rhe events resulting In death)
<br />LAST
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<br />PARr I. Enter the dlaJ.n.Qf.Qv.mlla--diseasp,s, injuries, Or compllcations--that directly caused lhe death. DO NOT enler termInal events such as cardiac arrest,
<br />respiratory arrest, or vantricular IIbrlllallon without 'hawing the atlology. DO NOT ABBREVIATE. Enter only OM ceuse on a line. Add addlllonalllnes II nacessary. ,
<br />IMMEDIATE CAUSE: . . '\ ' onset to death
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<br />IMMEDIATE CAUSE (Final ~I~ S'"O\& -<.-.k~_<\.e..~ (Y\ D~ \~ __ _~~\,)~~_.
<br />dl.eese or condition re.ultln9 DUE TO, OR ..is!fcONSEQUENCE OF: , on,et 10 dealh
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<br />..-----.--- ------'----- --.
<br />I onsel to death
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<br />APPROXIMATE INTERVAL
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<br />..-'--...--.,,-
<br />DUE TO, OR AS A CONSE:OUENCE: OF:
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<br />__-----L _ n___
<br />, on'elto death
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<br />(d)
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<br />1 B. PART II. OTHER SIGNIFICANT CONDITIONS-Condlllon, contributing to the dealh but nol resulling In the underlying cause given In PART I.
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<br />..~'._"._-_._'-' .'.'-',.--. .-.-.-
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<br />- ...1 '". w," "'''. ALEXAMINER----
<br />. OR CORONER CONTACTED?
<br />DYES IJ NO
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<br />20. IF FEMALE: 21a_ MANNER OF DEATH 21b.IFTRANSPORTATION INJURY 210. WAS AN AUTOPSY PERFORMED?
<br />o Not pregnant within past year 0 Natursl 0 Homicide 0 Driver/Operator 0 YES Xl NO
<br />lJ Pregnant altlme 01 dealh 0 AccldentlJ Pending Invesligation IJ Pessenger .__._.
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<br />o NOI pregnant, bUI pregnant within 42 days of death 0 Suicide 0 Could nol be determined W Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o NOI pregnanl, but pregnant 43 day' to 1 year betore death W Other (Specify) COMPLETE CAUSE OF DEATH?
<br />LJ Unknown iI pregnant within Ihe past year _ .._."._ 0 YES ilNO
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<br />22a DATE OF INJURY (Mo, D~t, ~r) LT1ME OLI~UR: L0.C-~ OF 1't!!J.fiY,AlliomA !Rem "'"01 lao!aly..ol!!<:I!.bu"rll"O 00"0'''''110" '~p<;<>IIrl-_
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<br />"'22dINJURYATWORK?' J 22; DESCRI8EHOWINJURYOCCURRED - -- -,- -- -- - - --
<br />DYES 0 NO
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<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITYIfOWN STATE ZIP CODE
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<br />-----Qe.0'\fN\i_
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<br />23a_ DATE OF DEATH (Mo_, Day, Yr.)
<br />()\_I()_ d.Ot>~
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<br />23b. DATE SIGNED (Mo" Day, Yr.) 23c_ TIME OF DEATH
<br />() ~- \ ~- ~\)Olo ~.~ \ ~ m
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<br />24a. DATE SIGNED (Mo" Day. Yr.)
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<br />24b_ TIME OF DEATH
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<br />23d. To the beSl of my kno~~th occurred at the time, date and place
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<br />~e~use~~n~\::tle) ~ ~ ~
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<br />240. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCW DEAD
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<br />-.-._- --'.'--'.-.._-
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<br />24e. On the basIs of examination and/or investigation, in my opinion death occurred at
<br />the time, dale and place and due to the cause(s) staled. (Signature and Tille) ~
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<br />2S.DIDTOBACCO USECONTRiBUTE:TOTHE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
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<br />LJ YES ll'f NO 0 PROBABLY IJ UNKNOWN 0 YES teiNO __ Not Applicable if 26a Is NO~ES ~O_
<br />27.'NAME, Trj-LEANo7;:DDRESs OF CERTIFIERlPHYSICIAN. CORONER;S PHysiCIAN OR COUNTVATTORNEY) (Type orPrini)"-
<br />J.J. Cannella M.D. 729 N. Custer Ave., Grand Island, NE. 68803
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<br />28a. REGISTRAR'S SIGNATURE
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<br />2Bb_ DATE FILED BY REGISTRAR (Mo., Day, Yr.)
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<br />MAR 1 5 2006
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