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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HPMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COP.Y OF THE QRIGINMiFiiEcdRlniNoFlLE WITH
<br />THE NEBRASKA HEALTH AND HuMAN SERVICES SYSTEM, VITAL STAPS';(JCSSECTfON,-'WtJICH IS
<br />
<br />:::;::~::::::~TORY FOR VITAL RECORDS. ~.:".~. rz;. ""-'--"...2. ".~.
<br />APR 2 1 2006 [!~!~~:C~%~:
<br />LINCOLN, NEBRASKA 2006 0 t 8 2 3 HE,,~L i"'A!#!ffW1~~!+%;ERVjCES
<br />
<br />.~
<br />
<br />
<br />STATE OF NEBRASKA - DEPARc~~;rF~~~i.~_~Qf~~_~Ai;VI~::~~~~~_AN~ SUPPORfi 6 2 At 381
<br />
<br />1, DE,C~D~NT'S-NAM~ (First, Middl., Lasl, Suffix) 2, SEX 3, DATI, OF D~ATH (MO., Day, Yr.)
<br />DewaY!1:~,m_,!!g?_I!I~_~ ,P911Kll3.s...__ _~_m__ ril 14 2006
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a, AGE. Last Birthday 5b, UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo" Day, Yr,)
<br />n_n' .'.'. ~_..,~~
<br />(Yrs,) 75 MOS, DAYS HOURS MINS,
<br />March 24,1931
<br />
<br />Grand
<br />
<br />Island,
<br />
<br />Nebraska
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />
<br />728-01-8950
<br />
<br />8a, PLACE OF DEATH
<br />Ililll.E'lJlIL
<br />
<br />jfllnpatlant
<br />o EHIOutpatlant
<br />
<br />QllifB: 0 Nursing Homa/LTC 0 Ho,pice Facillly
<br />
<br />!
<br />I;J
<br />
<br />8b, FACILlTY-NAM~ (I! not Inslitution, give <treel and numb.r)
<br />St. Francis Medical Center
<br />
<br />U Decedent's Home
<br />
<br />OtxJl\
<br />
<br />o Olher (Speclly)~__._.
<br />
<br />
<br />8e. CITY OR TOWN OF DEATH (Includ. lip Cod.)
<br />:* ,t G ran d I s 1 and
<br />," j"
<br />( ,;j,
<br />ti"Qj; 9a, RESIDENCE-STATE 9b, COUNTY 9c, CITY OR TOWN
<br />:;~'i Neb r ask a Hall G ran d I s 1 and
<br />;~x. 9d STREE-;:-AND NUMBER '---- -Y~P_T N-o--191~8 ~~E 3
<br />
<br />I; ':~?~ii~.~~; ~.Ji~,'krn~\j ,;;tIo,." ".;"~ ;""",,, "'"" I"~ "".~, ,,'hi"""' ".. ~~" M~
<br />
<br />III U "w,,,. ,"' _","" U w~"OO U ",,,,_ 0 "",","" Kat her i n e_N_a b ity
<br />
<br />./11>:" 11, FATHER'S-NAME (First, Middle, Last, Sulllx) 12, MOTHER'S-NAME (First, Middl., Maidan Surname)
<br />';!~0 Michael Basil Maude Agnes Byrd
<br />i'~f~ 13, EVER IN U,S, ARMED FORCES? Give dates 01 ,ervice II yes. 14e, INFORMANT-NAME ".. ..---...--- , 4b. RELATIONSHIP TO DECEDENT
<br />.l~~', (YeJ~~unk)'li...24 / 49-SJ_?1! ,?O Ka therine Dou las wi f e
<br />
<br />I~: 15 ~:~a~ OF DI~~:~:::~ JV;V::YJ _ ~~,4di~ _ '6b1~~iS~:~_ 160, DATE (Mo" Day, Yr,)
<br />
<br />o Cr.mallon 0 Entombm.nl 16d CEMETERY, CREMATORY OR OTHER Li(9ITION CITY I TOWN STATE
<br />
<br />o Removal OOth.r(Speclly) Westlawn Memorial Park Cemetery, Grand Island, Nebraska
<br />
<br />17a, FUNERAL HOME NAME AND MAiliNG ADDRESS (Straet, City orTown, Stala)
<br />All Faiths Funeral Home,
<br />
<br />8d. COUNTY OF DEATH
<br />
<br />68803
<br />
<br />Hall
<br />
<br />9g, INSIDE CITY LIMITS
<br />iXi YES 0 NO
<br />
<br />
<br />.....--...---:
<br />
<br />PART I, Enter tha ~.s--dlea.ses, InJuries, or oomplloatlone--thal dlreelly eaueed Ihe dealh, DO NOT entar terminal avents such as cardiac ."a.t,
<br />rasplratory arrest, or v.nlrlcular Ilbrillation wilhoul ,howing the .tlology, DO NOT ABBREVIATE, Enlar only ona cau.. on alln.. Add addillonelline, II necessary,
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In dealh)
<br />
<br />IMMEDIATE CAUSI'
<br />
<br />__ (r \?~ej'yq~\OJ~ L"\oJc.e....
<br />
<br />DUE TO, OR AS A CONSEOUENCE
<br />
<br />onset to dea.th
<br />
<br />\ 2~Ou(S __
<br />
<br />onsat to daeth
<br />
<br />Saquantlally IIs1 conditions, II
<br />any, leading to the cause listed
<br />on line a.
<br />Enter lho UNDERLYING CAUSE r r-.
<br />(dleaasa or Injury Ihallnltlatad (c) l---V
<br />Ihoov.nl. ",.ultlng In d..lh) DUE TO, OR AS A NSEQUENCE OF:
<br />LASr
<br />
<br />________ (d) N~_~_SmJ.~\\ ~\ \ ~y:0~~..k~ _"__..~_
<br />
<br />18, PART II, OTHER SIGNIFICANT CONDITIONS-Conditions contrlbullng to tha dealh but not ra,ultlng In ~nd.rIYlng oausa giv.n In PART I.
<br />
<br />{b)....f")\;,s4<V.~\-~L
<br />
<br />DUE ~R AS A CONSEQUENCE OF:
<br />
<br />~-~a--li~<;-e.-
<br />
<br />;-c:.-
<br />
<br />onsel to daeth
<br />
<br />:0
<br />
<br />on sat to death
<br />
<br />19, WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />~;f't~AEC~U,,"..C\-:\_f-I:S~a,~~~~-'
<br />
<br />
<br />
<br />o NOI pregnant wIthIn pas I year \J.'l'fatural 0 Homicide
<br />
<br />
<br />o Pr.gnant at tlm. 01 death 0 AccldentO Pending Inv.stigation
<br />
<br />DYES
<br />
<br />o NO
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<br />21 b, IFTRANSPORTATION INJURY 210, WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />o Suicide 0 Could not bB determined
<br />
<br />o Passenger
<br />Q Pedaslrian
<br />I:l Oth.r (Sp.clfy)
<br />
<br />DYES
<br />
<br />~
<br />
<br />U Not pragnant, bUI pragnant within 42 days 01 d..th
<br />o Not pragnant, bUI pregnant 43 days 10 1 year balm" daatll
<br />o Unknown if pregrlant wllhin the past year
<br />
<br />21 d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />U Y~S IJ.l.--i<r6
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />
<br />m
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY.At home, farm, str.el, laclory, office building, eonetructlon ,lte, ate, (Spacify)
<br />
<br />22d, INJURY AT WORK?
<br />U Y~S ~
<br />
<br />221, LOCATION OF INJURY. STREET & NUMBER, APT, NO,
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />liP CODE
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<br />23a. DATE OF DEATH (Mo., Day, Yr,)
<br />
<br />_~~P_I i 1 ...li.,___7J2.9_Q__~_~__
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr,)
<br />
<br />24b, TIME OF DEATH
<br />
<br />01 : 49 A.m
<br />
<br />,.,::Ji~
<br />"'~~
<br />h~
<br />Q. n. ;.x ::;
<br />E.<II 1: z
<br />8ffizo
<br />..z::>
<br />"'00
<br />t2ct:U
<br />8~
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo" Dey, Yr,) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examInatIon and/or InvestIgation, in my opinion death occurred at
<br />tha tim., data and plac. and duo to the cau,.(s) 'tated.(Signelure and Title) "
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERW?
<br />
<br />_~C!_t::!____lJ~~OBABLY 0 UNKNOWN 0 YES __~s>_
<br />27. NAM~, TITLE AND ADDRESS OF C~RTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. or Print)
<br />Ryan Crouch, D.O., 800 Alpha St. Grand Island
<br />
<br />26b. WAS CONSENT GRANTED?
<br />Nol Applicable II 26a Is NO 0 YES f)4NO
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />Nebr
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />APR 2 0 2006
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