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<br />STATE OF NEBRASKA _"..
<br />
<br />,~_WHEN-THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTHAWitPMltN'SE,RVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAkflECDRDONFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATf$TjCSSECTtoii?WHICH IS
<br />
<br />:~=;::::CS;ORY FOR YfTAL RECOROS. ~~~ER
<br />MAR 0 9 2006 2 0 0 6 0 8 8 3 6 "ASSII3TANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA tii;,iiit(AIt!P HUMAN _SERVicES
<br />
<br />,. DECEDENT'S.NAME
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICESFlNANC5ANO S6PPORTO 6 .._2....2 3 8 4
<br />CERTIFICATE OF DEATH
<br />---.. . ..._--,' ",., ...".. .,.~~~ ,.-....
<br />(First, Middle. Last. Suffix) 2. SEX 3.pATE OF DEATH (Mo., D~, Y'J
<br />Lilamae Kimball Female February 27, LOo6
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE-LeSI Birlhday 5b. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />82
<br />
<br />
<br />6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />
<br />Exeter, Nebraska
<br />
<br />1923
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />ea. PLACE OF DEATH
<br />!:!.Q.QElIAJ.;
<br />
<br />~ Inpatiant Q!t!E8: D Nursing Home/LTC 0 Hospice Facility
<br />
<br />_5-.21-20-5327
<br />Bb. FACILITY-NAME (II not institution. giva straat and number)
<br />
<br />o ERIOutpatlent 0 Decadent's Homa
<br />
<br />""',
<br />
<br />St_o. Francis Medical C~~J:_~~_
<br />8e. CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />o [X)\ 0 Othar (SpeGity)
<br />8d. COUNTY OF DEATH
<br />
<br />Gratl(t_:ISl!;!,l!d 68803
<br />9a. RESIDENCE-STATE ~UNTY
<br />
<br />Nebraska _____J 'Hal~n.
<br />9d. STREET AND NUMBER
<br />
<br />Hall
<br />
<br />9c. CITY OR TOWN
<br />
<br />....NQ...e::::.l~_nt.:l11 y
<br />lOa. MARITAL STATUS AT TIME OF DEATH :lfI Married 0 Nevor Married
<br />
<br />Grand Island
<br />
<br />--~NO 9f'Z::;~1
<br />
<br />lOb. NAME OF SPOUSE (First. Middla, Last. Suffix) If wife, give maiden nama.
<br />
<br />9g. INSIDE CITY LIMITS
<br />G Y~S 0 NO
<br />
<br />o Married, but separatad 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Ervin Kimball
<br />
<br />11. FATHER'S-NAME (Flrsl,
<br />Thomas
<br />
<br />Middle, Last,
<br />Cleveland Hart
<br />
<br />Sulllx)
<br />
<br />12, MOTHER'S.NAME (First,
<br />Viola
<br />
<br />Middla,
<br />Velmira
<br />
<br />Malden Surname)
<br />Tougard
<br />
<br />o Entombment
<br />
<br />16a, EMBALMER.SIGNATURE S'~SE NO. ---
<br />--" %;':-~R~--~-- #/5,25"
<br />
<br />16d. CEMETERY. CREMATORY OR H~R LOCATION CITY / TOWN
<br />
<br />
<br />14b. RELATIONSHIP TO DEC~DENT
<br />
<br />13. EVER IN U,S, ARM~P FORCES? Give detes of servlca if yas.
<br />(Yes. no, or unk.) No
<br />
<br />15, METHOD OF DISPOSITION
<br />~ Burial 0 Donellon
<br />
<br />ughter__
<br />18c. DATE (Mo" Day, Yr. )
<br />
<br />o Cremation
<br />
<br />Dl_2,
<br />STATE
<br />
<br />U Ramoval 0 other (Specify)
<br />
<br />Westlawn Memorial Park Cemetery
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />
<br />
<br />16, PART I. .nlar tha !<!li!l!l.21.~y.~nla--dlseases, InJuries. or complications-that directly caused the death. DO NOT antar tarmlnalevents such as cardiac arrest,
<br />respiralory arrast, or vantricular fibrillation without showing the atiology. DO NOT ABBREVIATE, Enter only one cause on a line. Add addltlonalllna. It nacassary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMWIAT~ CAUSE:
<br />
<br />onsat to daath
<br />
<br />IMMEDIATE CAUSE (Final
<br />dlsea!iEl or condition resulting
<br />in daath)
<br />
<br />(a) {' <?I'll 0/" I ~T:.J4(-( {!_ ~v.,
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />~1/1 e(if
<br />
<br />onselto death
<br />
<br />
<br />Sequentially list conditions, II
<br />any, leading 10 the cause listed
<br />on line a.
<br />Enter the UNDERLYING CAUBE
<br />(disease or Injury that Inltlatad
<br />the evenls r.sultlng In daath)
<br />lAST
<br />
<br />(b) /VI yD(,.-rJ,.....( ]'v-- .r:,,..i./ '"""-' !.. /IN,,!I''',,,,, I'",
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />L../',:-K]
<br />
<br />onset to death
<br />
<br />(0)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset 10 death
<br />
<br />(d)
<br />
<br />o t"" rIfle .JL'
<br />
<br />tl TN
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORON~R CONTACTED?
<br />
<br />DYES 0 NO
<br />
<br />18, PART II. OTHER SIGNIFICANT CONDITIONS.Conditlons contributing 10 the death but not rasultlng In the underlying causa givan in PART I.
<br />
<br />ffi
<br />ii:
<br />E
<br />tl
<br />E
<br />
<br />20, IF FEMALE:
<br />o Not pregnant within past year
<br />U Pregnant at lima 01 death
<br />
<br />21a~NNER OF D~ATH
<br />~atural 0 Homicide
<br />
<br />o AccldentO Panding Invastigation
<br />
<br />21b, IFTRANSPORTATION INJURY
<br />o Drlver/Oper'Ior
<br />
<br />o Passangar
<br />
<br />o Pedestrian
<br />
<br />21 c. WAS AN AUTOPSY PERFORM~D?
<br />
<br />DYES
<br />
<br />R,-NO
<br />
<br />25. 010 TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />D~~s 0 NO DPROBAB~~_ ~UNKNOWN _ 9.YES ~_~_o__
<br />27. NAME. TITLE AND ADDRI'SS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNI'Y) (Type or Print)
<br />
<br />~~ D~~,,~,~,~,::;:.~~ng m,North Cnster Grand Mand. Nebraska
<br />
<br />
<br />o Not pragnant, but prognant within 42 days 01 dealh 0 Suicide 0 Could not ba determined
<br />o Othar (Speclly)
<br />Jl 0 Not pregnant, bUI pregl).nt 43 days to 1 yoar before desll> COMPLETE CAUS~ OF DEATH?
<br />
<br />'! _ 0 Unknown If pregnant w,lh,nthe past yaar __ 0 Y~S ;l'NO
<br />
<br />'-'8 ' ~DATli"OF';NJURY (Mo., Day, Yr.) 22b TIME OF INJURY ~Pi:ACE OF INJURY-At i1Ome:i;rm, str..-t. iaclory: ~ffloe building. construction ~l1a, otc-(spoClfy)
<br />
<br />~ m L__
<br />.~ 22d.INJURY AT WORK? -\ 2';;; D.SCRIBE HOW INJURYOCCURRED - - -
<br />DYES 0 NO
<br />-----
<br />221, LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />CITYITOWN
<br />
<br />STIlJE
<br />
<br />ZIP CODE
<br />
<br />230. D.AT7E OF. D.AJH (MO.., Day, Yr.)
<br />~) 'i') f b C,
<br />....____.._....."'u_
<br />23b. DATE SIGNE7D (M.. n" Day, Yr.)
<br />,) I OJ ()(.
<br />
<br />24a, DATE SIGNED (Mo., Day, Yr,)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />z,..
<br />li'Q~
<br />n~
<br />c,1). :.x ::;
<br />~""'i:i5
<br />8ffi z
<br />,8z=>
<br />~~8
<br />O~
<br />uc
<br />
<br />m
<br />
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr,) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. 1'0 the besl of my knowladgo, death occurred at (he lime, date and place
<br />and dua to tha cause(sl staled, (Signalura and Title) "
<br />
<br />/:)-1j!,4r;11 ~;--' 5'
<br />
<br />248. On the basIs of examination and/or investlgallon, in my opinion death occurred al
<br />Ihellme, data and place and due 10 tha causa(s) stated. (Signalura and Tilla) "
<br />
<br />26b. WAS CONSENT GRANToD?
<br />
<br />Not Applicabla if 26ai, NO .__0 YES ~. NO
<br />,
<br />
<br />68803
<br />
<br />
<br />28b. DATE FIL~D BY REGISTRAR (Mo" Dey, Yr.)
<br />
<br />MAR
<br />
<br />9 2006
<br />
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