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<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OFTHENEBRASKA HEALTH A"!/)/Jp!!!AN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGIN~t;qf!Dpll'=&l.LE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA'!fJT'IPS-Sl!C11€J~,WH[CH IS
<br />THE LEGAL DEPOSITORY FOR VI!AL RECORDS. ~..".'.'==-..-.'... ~.:::~. ..'....,'-..' '-..I'j...... l..!._~'."."'~.'~....'.'..'-t.....,
<br />
<br />DATE OF ISSUANCE "'. __, _' f).-"- ~:=. c:.
<br />O 0 7 0 0 0 83 > ..... -- iANLE'iS. COOPER
<br />2' A.~.!ANT s.rAi{,fiE~ijT{iAR
<br />HEAL T"""IViOJlIj~ :SERVICES
<br />
<br />AUG 3 0 2006
<br />LINCOLN, NEBRASKA
<br />
<br />o
<br />'\
<br />
<br />
<br />STA...:TE OF NEB...R. A.' SKA - DEPARTMENT. .OF HEALTH...AND HUMAN. SERVICES FIN'ANCE A-ND.S. UPPOlfli. 6.. 2'.9,.' l' 0...0' )
<br />---. ___. __ CERTIFICATE; OF DEATH_. U _..' Q
<br />DECeDeNT'S.NAME (Flrsl, Middle, Lasl,
<br />Ada Mae Cline
<br />
<br />.. 4.' ..C...ITY AN~ S.TA. Te OR Te~~IT.O. RY, OR ~OA..EIGN COUNTR. Y OF SIRTHFAGE.Last Birlhday ;b. UNDER ~Y'EAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />__ Milford, Ne~rask_a____ I (Yr..) 85 MOS. rAYS HOURS MINS. June 6, 1921
<br />
<br />7. SOCIAL SE;CURITY NUMBER Ia PLACE OF DEATH .---
<br />508-14- 5455 1:fl2S.ETIAL.: Kllnpall.nl Q1I:fEB: 0 Nursing Home/LTC [J Hospice Facilily
<br />8b. FACILlTY.NAME (If not Inslllution, give slraat -.Ilnd numbar) - '". - -- "" --CJ"E-R/Oullloflem Cl D"""denreHom.- . .
<br />St. Francis Medical Center
<br />o [Q\ OOlh.r(Sp.cl,y)_ _
<br />8c. CITY OR TOWN OF DEATH (IncludaZipCoda) '-688-0-3" - ~UNTYHOFaDIEAITH . --.-.-
<br />Grand Island ~_
<br />9a.RESIDENCE.STATE ~9b.COUNTY. . :19c CITY OR TOWN - .
<br />____L Hall Grand Island
<br />- - '~NO 91 ZIPCO~-~IDECITYLlMITS
<br />1919 N. Sherman Blvd. ~ 68803 ~ XI YES 0 NO
<br />~,.. """,,,'^,,'^,,,,,,,,"'" ~ ",,,,,, Q "~,"",,,, TO "'"' ""'"" ,",;" """", '"" '""'''' ."" .;, ";'00' ,,,.. . - -
<br />
<br />o Married, but ..paral.d 0 Wldow.d 0 Dlvorc.d 0 Unknown William Cline
<br />
<br />--1~ FATHE;;S.NAME ~~~ster ~ ~~~k SUffITTHER'S'NAME (;~t6da --~ ----~MG.n Surnamo)
<br />
<br />13. EVER IN U S. ARMED FORCES? G,VO d-.Ie' 01 .arvlc.1f ;.~FORMANT'NAME . - . . . .... ~~b RELATlONS-~IP TO DECEDENT
<br />(Vas,no,Orunk) No ~ William Cline Husband
<br />
<br />15. ~::r~a~ OF DI~::~::I:~ f6a:__EMSAL;:~-~N~:~ alll!ed - ~SE ~_:~ 1 6C~:~EU(~~' D~Y8Y~') 20;6
<br />
<br />LXCremation Cl Enlombmont 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />
<br />Suffix)
<br />
<br />2. SEX
<br />Female
<br />
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />_August .17, 200f)
<br />
<br />
<br />,........,
<br />
<br />o Ramoval 0 Olhar (Sp.clfy)
<br />
<br />Westlawn Memorial Park Crematory
<br />
<br />Grand Island, Nebraska
<br />
<br />~'---"'-'''--'''-''''-
<br />17a. FUNERAL HOME NAME AND MAiliNG ADDRESS (Street, City orTown, Slato)
<br />Apfel Funeral Home, 1123 West Second,
<br />
<br />. PART I. Enter the chain 01 eVAnl~--diseaseSr InJurIes, Or compllcatlons--Ihat directly caused the death. 00 NOT enter lermlnal events such as cardiac arrasl,
<br />respiratory arrast, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE, Enter only one cause on a line. Add addlUonallines jf necessary.
<br />
<br />
<br />17b. Zip Coda
<br />68801
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<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In death)
<br />
<br />la)
<br />
<br />
<br />-""
<br />-:-'~~~-.i:::
<br />R AS A CONSEQUENCE OF:
<br />
<br />I
<br />I
<br />
<br />
<br />: ::z:~
<br />
<br />
<br />I
<br />I
<br />I
<br />I Onset to death
<br />I
<br />I
<br />-------L..__
<br />I onsot 10 dealh
<br />I
<br />I
<br />
<br />S.qu.ntlally list oondltlon., If (b)
<br />.ny, loading to the c.uaaU.t.d DUE HJ, OR AS A CON'SE'QUENCE OF:--
<br />on line a.
<br />Enl8rth. UNDERLYING CAUSE
<br />(dl..... or Injury thet Initl.tad (c)
<br />the events resulting in death)
<br />lAST
<br />
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS.Conditions contributing 10 the dealh but not r.sultlng in tha und.rlying osuse givan In PART I.
<br />
<br />"..___. .__n._,_,,___ .._'__.'.'.
<br />
<br />o Suicide U Could not be dBterminerl
<br />
<br />21 b. IF TRANSPORTATION INJURY
<br />CI Drlv.r/Operator
<br />
<br />U pass.ngar
<br />
<br />o Pedestrian
<br />
<br />'-TI9. WAS MEDICAL EXAMINER---
<br />OR CORONER CONTACTED?
<br />
<br />Ll YES 0 NO
<br />__,',_,__n".
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />CI YES ~O
<br />
<br />20. IF FEMALE:
<br />~Ol pregnanl wllhln past year
<br />o Pragnanl.t limo 01 d.alh
<br />o Nol pr.9nanl, but pr.gnanl wilhin 42 days 01 dealh
<br />o Nol pregnanl, bul pr.gn.nI43 d.y. to t y.ar belora daalh
<br />o Unknown if pr.gn.nt within Iho p.sl y..r
<br />
<br />21 a. MANNER OF DEATH
<br />~alural [J HomIcide
<br />
<br />o Accid.nlCl Pending Inv.stlgallon
<br />
<br />o other (Spacify)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />22c. PLACE OF INJURY.At hnm. I m ,tr
<br />~
<br />
<br />II I r~tr~l;.l:~" ""I..., .".... (~rleottyt-.--'--,. -..,-..---
<br />
<br />220. DESCRIBE HOW INJURY OCCURReD
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />Z
<br />>'<(
<br />j!;j
<br />]!~
<br />c..::E:::i
<br />Eo..z
<br />8 g>o
<br />QII:C
<br />'" c
<br />~!
<br /><(
<br />
<br />2:~ DAlE OF DEATH &> 07;) 7 Ie> G . .__...
<br />
<br />23b. DATE SIGNED (Mo., Day, r.) 23c. TIME OF DEATH
<br />oG m
<br />
<br />24.. DATE SIGNED (Mo" D.y, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />
<br />b"~~
<br />ll-a:
<br />-~p
<br />tKS::i
<br />E"'>-Z
<br />8ffi!z0
<br />.. z =>
<br />"'00
<br />t2a::u
<br />o~
<br />Uo
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., D.y, Yr.) 24d. TIME PRONOUNCED DEAD
<br />
<br />m
<br />
<br />24e. On the basis 01 examination and/or Invesligation, in my opInion death occurred at
<br />Ih.lim., dat. .nd pl.ca and du.lo Ih. c.use(s) stal.d. (Slgn.lur. and Tillo) T
<br />
<br />
<br />25. OIDTOSACCO USE CONTRI TETOT' DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />
<br />[J YES '&tNO 0 PROBABLY 0 UNKNOWN 0 YES~NO NOIAPPllc.bleif26aiSNO_~ YES 0 NO
<br />-'27. NAM~'ADDRESS OF CERTiFIER (PHYSICIAN: CORONER'S PHYSICIAN OR COUfl~ORNEY) (Typa or irini)'
<br />Gordon J. Hrnicek M.D. 729 N. Custer Ave., Grand Island, Nebraska 68803
<br />
<br />26.. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., D.y, Yr.)
<br />
<br />AUG 23 2006
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