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<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTHAND-HtlMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECOiiilOt'l.E/LE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL siItrISTtCSSECi<<>>CW.HICH IS
<br />
<br />
<br />:~~i~7:~:ORYFO;;~ ;;;;03 . i~iw~ER
<br />
<br />
<br />'. ASSlMANT_S.TATEM.GlSTRAB
<br />LINCOLN, NEBRASKA HEALTH AND'HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AN.' D SUP'PbR6' '. ,"--2-"6'. '. 7' 1'. . O.
<br />CERTIFICATE OF DEATH '. ....' U ". ! J. . .
<br />- -
<br />
<br />1. DECEDENT'S-NAME IFirsl, Middle,
<br />__pelber.!,. Byr'?~ Battles
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />2. SEX
<br />
<br />Male
<br />
<br />50. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />3. DATE OF DEATH IMo.. Day, Yr.)
<br />June 15, 2006
<br />
<br />6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />
<br />Sa. AGE.Last Birthday Sb. UNDER 1 YEAR
<br />(Y,..) MOS. DAYS
<br />
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<br />
<br />Omaha, Nebraska
<br />7. SOCIAL SECURITY NUM BER
<br />
<br />February 8, 1918
<br />
<br />88
<br />
<br />ea. PLACE OF DEATH
<br />HOSPITAL:
<br />
<br />D Inpallenl
<br />
<br />OTHER: I2\l Nursing Home/LTC D Hospice Facillly
<br />
<br />505-12-3161
<br />eb. FACILlTY.NAME (II not Institution, give strael and number!
<br />
<br />D ER/Oulpallenl
<br />
<br />D Decadent's Home
<br />
<br />Dro\
<br />
<br />D Ott,.r(SpeCI~)
<br />
<br />Wedgewood Care Center
<br />ac. CITY OR TOWN OF DEATH Ilnclude Zip Code)
<br />
<br />Grand Island 68803
<br />9a. RESIDENCE.STATE
<br />
<br />ed. COUNTY OF DEATH
<br />
<br />Ilb. COUNTY
<br />
<br />
<br />9g.INSIDE CITY LIMITS
<br />
<br />Gil YES D NO
<br />
<br />Nebraska
<br />ad. STREET AND NUMBER
<br />
<br />Hall
<br />
<br />91. ZIP CODE
<br />
<br />1223 W, 10th Sl.
<br />lOa. MARITAL STATUS ATTIME OF DEATH iii Married D Never Married
<br />
<br />68801
<br />jOb, NAME OF SPOUSE (First, Middle, Last, Sulflx) II wife, give maiden name.
<br />
<br />D Maflled, but separated D Widowed D Divorced U Unknown
<br />
<br />Delot'es 0 Thibault
<br />Sulllx) 12. MOTHER'S.NAME IFirst,
<br />
<br />Mabel Simmons
<br />
<br />Middle,
<br />
<br />Malden Surnama)
<br />
<br />Last,
<br />
<br />11. FATHER'S.NAME IFlrst,
<br />Will Battles
<br />
<br />Middle,
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dales 01 service ilyes. 14a.INFORMANT.NAME
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Wife
<br />
<br />16c. DATE (Mo.. Day, Yr.)
<br />
<br />June 20, 2006
<br />
<br />STATE
<br />
<br />IYes, no, or unk.) No
<br />15. METHOD OF DISPOSITION
<br />IXI Burial D Donalion
<br />
<br />Delores 0 Battles
<br />
<br />
<br />16b. LICENSE NO.
<br />1000e
<br />
<br />CITY /TOWN
<br />
<br />D Crematlon D Enlombment
<br />
<br />D Removal U Olher (Spacily)
<br />
<br />Westlawn Memorial Park Cemetery
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreet, Clly or Town, Slale)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, NebraSka
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />
<br />CAUSE OF DEATH (See Instructions and examples)
<br />18, PART I. Enler lhe ~J~--diseases, injuries. or compllcallons--Ihal dlreclly oaused Ihe death. DO NOT enter terminal evenls such as cardiac arresl,
<br />respiratory arrast, orvenhlcular Jlbrillalion wilhoul,howlng the etlology. DO NOT ABBREVIATE. Enleronly ona CaUSe on a line. Add addltlonalllnes II nacassary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />I
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<br />
<br />
<br />
<br />(a)
<br />
<br />IMMEDIATE CA USE (Fnel
<br />dlstlS. 01' coodlllon retuning
<br />n dteth)
<br />
<br />Sequentially IIslcondltlons, II (b)
<br />eny, I.edlng 10 the tau.. 1I.led
<br />on Jlnea.
<br />Enter th. UNDERLYING CAUSE
<br />(dlua.. or Injury Ihel InlUaled (c)
<br />theov.nlllra.uIUng Ind.ath) DUE TO, OR AS A CONSEQUENCE OF:
<br />jAgf
<br />
<br />onset to death
<br />
<br />0~'-C-
<br />
<br />ons.llo dealh
<br />
<br />onset to dealh
<br />
<br />(d)
<br />
<br />1 B. PART II. OTHER SIGNIFICANT CONDITIONS.Condlllons contribuling 10 Ihe deelh bul nol resulllng In Ihe underlying causa given in PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES D NO
<br />
<br />21 c, WAS AN AUTOPSY PERFORMED?
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<br />21 b.IF TRANSPORTATION INJURY
<br />D D~ver/Op.ralor
<br />
<br />D passanger
<br />
<br />D pedesll1an
<br />
<br />D Other (Speclly)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />COMPLETE CAUSE OF DEATH?
<br />D YES Ii:I1J'i1
<br />
<br />21 a. MANN~ OF DEATH
<br />Q1(a'iural D HomiCide
<br />
<br />20. IF FEMALE:
<br />
<br />D Not pregnanl wllhln pasl year
<br />
<br />D Pregnanl al lime 01 death
<br />
<br />U Nol pregnant, bul pregnant within 42 days 01 death
<br />
<br />D Not pregnanl, bul pregnanl43 days 10 1 yearbelore dealh
<br />
<br />D Unknown II pregnanl wilhin the pasl year
<br />
<br />DYES
<br />
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<br />
<br />D AcoidenlD Pending Inves~gaUon
<br />D Suicide tJ COUld not be datarmlned
<br />
<br />22d.INJURY AT WORK?
<br />D YES ~
<br />
<br />
<br />ZIP CODE
<br />
<br />22a. DAle OF INJURY (Mo..LJay, Yr.)
<br />
<br />22t.TIME OF INJURY 220. PLACE OF INJUFiY.Alhom., larm, slr.-ol, laclory, ofllOO building, eonstllleilon allo, 010. (Spoolfy)
<br />m
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYiTOWN
<br />
<br />SllITE
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
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<br />24c. PRONOUNCED DEAD (Mo.. Day, Yr.) 24d. TIME PRONOUNCED DEAD
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<br />
<br />24e. On the buls of examlnallon and/or InvesUgallon, In my opinion doath occurred al
<br />Ihe lime, dale and place and due 10 lhe cause(s) slated. (Signature end Tille)",
<br />
<br />2Gb. WAS CONSENT GRANTED?
<br />Nol Applloable 11280 Is NO D YES ~
<br />
<br />._ 26.. HAS ORGAN OR TISSUE DON~EEN CONSIDERED?
<br />
<br />DYES 0 NO 0 PROBABLY ~KNOWN D YES ~
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or pnnt)
<br />
<br />R an Crouch D
<br />
<br />
<br />
<br />2ab. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />JUN 1 9 2006
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