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<br />".
<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANDH~M.AN SERVICES
<br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL.JJJ:CORfI'-.W:J.;fiLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT!f!m;~:~,(fi7'R!!'~!CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~J' ~. ...::.,c_:~.' ~;i;.',.
<br />
<br />DATE OF ISSUANCE - - .f!.. - . -' ,
<br />NO V 2 9 2005 2 0 06 0 5 3 97 . ~:~rAN:~tl;:te%~Z.~
<br />HEALTff~NQ.H~~NfleR~'9ES
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />..
<br />
<br />/)
<br />{
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<br />'~
<br />
<br />"___ S~A~E OF NEBR~SKA- DE~~~~~~~~~~~;~NQt~~~~~VICES FINANC~ sUPPo~~O 5 12939
<br />
<br />1. DECEDENT'S-NAME (Firsl, Middle, Lasl, Sufllx) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Frances May Sutton emale November 18, 2005
<br />
<br />--.."'-'-~-"._-,----- -.,----. .-..
<br />
<br />,..... .
<br />
<br />'J
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Lexington, Nebraska
<br />
<br />5a. AGE-Last Birthday
<br />(Yrs.)
<br />Bl
<br />
<br />5b. UNDER 1 YEAR
<br />MOS. ..1. DAYS
<br />
<br />
<br />6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />
<br />27, 1923
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />506-28-0935
<br />
<br />8a. PLACE OF DEATH
<br />tl.Q.S.f'lIAl.: ~ Inpatlanl
<br />
<br />tr ER/Oulpatient
<br />
<br />QTIillJ: 0 Nutslhg HomelLTC 0 Hospice Faclllly
<br />
<br />8b. FACILITY-NAME (If 0.01 institullon, give slree! and_nU_rI1.~~JL
<br />
<br />o Decedent's Home
<br />
<br />St. Francis Medical Canter
<br />
<br />9d. STREET AND NUMBER
<br />
<br />55 Venus Street
<br />
<br />'''~9b.COUNTY
<br />Hall
<br />.,- -"._-"'..
<br />
<br />o D)\ OOther(Specily)__
<br />-~d. COUNTY. OF DEATH
<br />Hall
<br />-- _..~-
<br />eo. CITY OR TOWN
<br />Alda
<br />
<br />BC. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island, 68803-
<br />
<br />ga. RESIDENCE.STATE
<br />Nebraska
<br />
<br />10a~ MA"RITAL STATUS'ATTIME OF DEATH ~-Marrled O-~;ver MarrIed
<br />
<br />~ge APT NO 9I.ZIPCODE--'''-~EC-ITY-LIMITS..
<br />68810- ___L~ YES 0 NO
<br />~ - -- -~., .- -....,..,.. . .
<br />10b. NAME OF SPOUSE (Flrsl, Middle, Lasl, Sumx) II wife, give maiden name.
<br />
<br />o Married, but separaled 0 Widowed 0 Divorced 0 Unknown
<br />
<br />John Bruno Sutton
<br />
<br />11. FATHER'S-NAME (FirSI,
<br />Carlos
<br />
<br />Middle,
<br />
<br />Lasl,
<br />Galvan
<br />
<br />Suffixl
<br />
<br />12. MOTHER'S.NAME (FlrSI,
<br />Fedencia
<br />
<br />Malden Surname)
<br />Avila
<br />
<br />3" '14b RELATIONSHIP.. TO D.E..CEDENT-
<br />Husband
<br />.", . -~
<br />16b. LICENSE NO. 160. DATE (Mo., Dey, Yr. )
<br />November 18, 2005
<br />
<br />--',. ., -_._-~..
<br />CITY I TOWN STATE
<br />
<br />Middle,
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dales 01 service if yes. Ha.INFORMANT-NAME
<br />(Yes,no,orunk.)No Mr. John Bruno Sutton
<br />
<br />15 METHOD OF DISPOSITION
<br />
<br />o Burial
<br />
<br />o Donation
<br />
<br />16a. EMBALMER.SIGNATURE
<br />
<br />Not;, embalm~~
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATIDN
<br />
<br />119 Cremation 0 Enlombmenl
<br />
<br />o Removal
<br />
<br />o Olher (Specify) Can tral Nebraska Cremation
<br />
<br />Gibbon
<br />
<br />Nebraska
<br />
<br />;'~::~:,;;/;.<:\;,,:~
<br />
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Straet, City or Town, Stalel
<br />orner-Lieske-Horner Mortuary 2421 Ave. A , P.O. Box 777, Kearney,
<br />
<br />18. PART I. Enler Ihe ffiaiJlJl~nh..diseases, InJuries, or complicalions--Ihat directly caused Ihe deeth. 00 NOT enler 1ermlnalevenls such as oardiac arresl,
<br />respiralory arresl, or ventricular flbrlllalion wllhoul showing the etiology. DO NOT ABBREVIAtE. Enter only one cause on a line. Add additional lines If necessary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />\ ~ft~
<br />\~~+
<br />
<br /><}~ r1..
<br />-t..\&,t.A..L
<br />
<br />I
<br />I
<br />
<br />I onsello dealh
<br />I
<br />I
<br />I
<br />I onsello dealh
<br />I
<br />I
<br />..I
<br />I onsel to death
<br />
<br />--:-~~b
<br />
<br />I onsol10 death
<br />I
<br />I It)
<br />
<br />~ cO~
<br />
<br />IMMEDIATE CAUSE: ^ ' .
<br />
<br />IMMEOIATECAUSE(Flna' (al \"LO"2_"~G'€Z".ns\f%-+~
<br />di.....oroondltlonre.ulllng DUETO,OR'ASAC NSEQUENGEOF:' -- ..-----
<br />In death)
<br />o -
<br />SequenUally 1I0t condillon., II (b) ,~~()-\...u...."."
<br />any, leading to tho cauoe listed "DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />~he& ~
<br />Ente'th. UNDERLYING CAUSE C _ '
<br />(dloo.se or Injury th.llnllleled (c) ...tJ'^~ i"A.!I._
<br />theeventsr..ulllng In death) "-'DUE TO, OR AS A' CONSE~~ENCE OF:
<br />
<br />LftST :-t. ~ j\..QA~ A ,
<br />(d) --__..
<br />
<br />L.j.~..L
<br />
<br />~~"--~
<br />
<br />'Y--5
<br />
<br />18 TRT II OTHER SIGl"""''' "'"""""""'"'"i ~"~.~~ 'o. :..~. om ~.'''"~" ,. "O","'o",~. r '0 ~1 '. 'I ~~:;:~;~'":::::,,
<br />__ ~_~ ~4 t-~o< ~.0"J t~~~ 'V'^-.dL\(,.<, LH'fj ~~.1)(P1!yES_~ NO
<br />20 IF FEMAL?: ~ 21a. MjlNNER OF DEATH 21b IFTRANSPORTATION INJURY 2~'WASANAUTOPSY PERFORMED?
<br />QII NOI pregnanl wllhln pasl year &alural 0 HomiCide 0 DrlverlOperalor
<br />o Pregnanl altime of dealh 0 AccldentO Pending Investigation 0 Passenger
<br />o Nol pregnant, but pregnanl wllhin 42 days 01 dealh 0 Suicide 0 Could nol be determinad 0 Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Not pregn.nl, bUI pregnant 43 days 10 1 year before dealh W Olher (Specify) COMPLETE CAUSE OF DEATH?
<br />o Unknown If pregnanl wilhin Ihe pas I year 0 YES Illl NO
<br />-22~ 1lATr~~JURY- (MO-:-'O: Yr.) - 122_b--TIME OF INJU~O' PLACE OF INJiiR~~, lar~ .traat'-factory, ol;lce building, constr~ctlon olla: elo (Speclfy~ --
<br />
<br />
<br />22d.INJURY AT WORK? 22a. DESCRIBE HOW INJURY OCCURRED
<br />
<br />o Y~S
<br />
<br />\ld NO
<br />
<br />o Y~S 0 NO
<br />
<br />221. LOCATIDN 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 />November 18. 2005
<br />~ ..-----. ....., ---',-".~.-
<br />
<br />24a. DATE SIONED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />23c. TIME OF DEATH
<br />3:40 a. m
<br />
<br />z>
<br />>.:! ~
<br />.c~a:
<br />ll>p
<br />tK;~
<br />IP'~~
<br />uffiz
<br />.81:55
<br />~a:U
<br />o ~
<br />uo
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo.. Oay, Yr.) Nd. TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To the best 0 my knowledge, death OCcurred at the time, date and place
<br />and due to Ihe ca~se(s..~ ~laledtgnaY') a~d TiUe) "
<br />
<br />LL' ""3 /)."~~.:J...q_ "/'vCQ)
<br />
<br />.24e. On the basis of examInation and/or investigation, in my opinion death occurred at
<br />the lime, date and pl.ce and due to Ihe causers) otated. (Signa lure and Tille) ...
<br />
<br />25. DID TOBACCO USE CONTRIBUTETDTHE DEATH? 260. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREO? 26b. WAS CONSENT GRANTED?
<br />
<br />-.__ c:J~__~<!_. 0 PROBABLY __~Q.\I,If'!. 0 YES___.iN?___ n_ NOI Appllcab.I~.il 26a Is NO 0 YES 0 NO
<br />27. NAME, TITLE AND AOORESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />William J. Landis, M. D. 2444 W. Faidley, Grand Island, NE 68103
<br />
<br />280. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILEO BY REGISTRAR (Mo.. Day, Yr.)
<br />WOV 2 2 2005
<br />
<br />:ii:.7~_
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