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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND -HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINA_ L RECOR"ALf_ILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI .msr SEC Aft, %"ICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. -
<br />DATE OF ISSUANCE'
<br />DEC 2 12006 200702116 � _ T9AILEYS. REGISTRAR
<br />ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH -AND HUMAN SER14CES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPOR 338.31
<br />CERTIFICATE OF DEATH
<br />1. OECEDENT'S -NAME (First, Middle, Last, Suffix) 2. SEX 3, DATE OF DEATH (Mo., Day, Yr.)
<br />Ruth Mae Franks Female December 11, 2006
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH _ 5a. AGE •Last Blrthday 5b, UNDER 1 YEAR 6c, UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs.) 68 MOS, I DAYS HOURS MINS.
<br />Gary, December 27, 1937
<br />Indiana
<br />7 SOCIAL SECURITY NUMBER
<br />574 -10 -8459
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />St. Francis Skilled Care
<br />Be. PLACE OF DEATH
<br />HOSPITAL: ❑ Inpatient 4I1JEB: ❑ Nursing Home /LTC %Hospioe Faculty
<br />❑ ER /Outpatlent U Decedent's Home
<br />❑ DOA ❑ Other (Specify)
<br />So. CITY OR TOWN OF DEATH (Include Zip Code) Sd. COUNTY OF DEATH
<br />Grand Island 68803 Ha11
<br />- - ... -..
<br />9a. RESIDENCE -STATE 9h, COUNTY 9c. CITY OR 7gWN
<br />Nebraska Hall Grand Island
<br />9d. STREET AND NUMBER 9e. APT. N0 9f. TIP CODE
<br />2910 Hancock Place 68803
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married U Never Married 10b, NAME OF SPOUSE (First, Middle, Last, Suffix) II wife, give maiden name.
<br />Ll Married, but separated Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Milburn G. Bradway
<br />18. EVER IN U.S. ARMED FORCES? Give dates of service II yes. 14a.INFORMANT -NAME
<br />(Yes, no, or unk.) NO Julie Smaha
<br />Bg, INSIDE CITY LIMITS
<br />YES U NO
<br />12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br />Genevieve G. Gumbiner
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />15. METHOD OF DISPOSITION
<br />16a. EMBALMER - SIGNATURE
<br />i6b. LICENSE NO.
<br />16c. DATE (MO., Day, Yr. )
<br />12, 2006
<br />❑Burial GDonation
<br />( Not Embalmed J
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<br />_
<br />December
<br />�Crematlon ❑
<br />EMTORY OR OTHER ER LOCATION
<br />i6d. CEMETERY, CREMATORY
<br />CITY/TOWN
<br />STATE
<br />❑Removal ❑ Other (Specify)
<br />Central Nebraska Cremation
<br />Service, Gibbon,
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Kleine Funeral Home, 3213 W North Front St., Grand Island, NE
<br />3,t 16. PART I. Enter the chain of events-,diseases, Injuries, or complications - -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />lin; respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary.
<br />r� E
<br />IMMEDIATECAUS:
<br />,a r
<br />die l4('!
<br />IMMEDIATE CAUSE (Final (a) Lr "S7L C"!l
<br />rl { disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF:
<br />in death)
<br />Sequentially list conditions, If (b) ���, �...__�__��,�•�
<br />any, leading to the cause listed DUETQORASACONSEQUENCEOF
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disesseor injury that Initiated (c)
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />(d)
<br />17b. Zip Code
<br />68803
<br />APPROXIMATE INTERVAL
<br />I
<br />I
<br />onsetlo death
<br />I
<br />.._-
<br />I onset io death
<br />I
<br />r ,t.-
<br />I onset to death
<br />I
<br />I onset to death
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<br />25. DID TOBACCO S CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? t;b, WA5 CONSENT GRANTED?
<br />L.1 VES ❑ _110 Cl PROBABLY ❑ UNKNOWN ❑ YES 210 Applicable if 26a is NO ❑ YES �O
<br />27. NAME, TITLE A.,... - -- -- --• _. _....
<br />ND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER' PHYSICIANOR COUNTY ATTORNEY) (Type orPrint)
<br />Dr Ryan D Crouch DO 800 Aloha
<br />28a. REGISTRAR'S SIGNATURE 2ab. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />23a. DATE OF DEATH (Mo., Day, Yr,)
<br />18. PART II.OTHER-8-10N IFICANT CONDITIONS•Conditlons contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br />24a. DATE SIGNED (Mo,, Day, Yr.)
<br />OR CORONER CONTACTED?
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<br />C � CF„ Jg❑ YES NO
<br />kIZ, '
<br />WAS AN AUTOPSYPERFORMED?
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<br />20. IFF ALE: RpFDE H 21 b.IFTRANSPOR TIONINJURY 21 c.
<br />-0 E3
<br />&N
<br />December ].J , ?_0..06
<br />Day, Yr.)
<br />$tural ❑ Homicide ❑ Driver /Operator Ed"�ot pregnant within peat year ❑YES [jLIQ�i
<br />a�_=
<br />ccident❑ Pendln Invest) ation ❑Passenger
<br />❑ Pregnant at time of death 9 9
<br />72a
<br />24c.PRONOUNCEDDEAD(Mo.,Day,Yr.)
<br />24d.TIME PRONOUNCED DEAD
<br />❑ Pedestrian U Not pregnant, but pregnant within 42 days of death uicide ❑Could not be determined 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />•0.w
<br />G Not pregnant, but pregnant 43 days toi year beloredeath LlOther(Speclly) COMPLETECAUSEOFDEATH?
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<br />❑ Unknown if pregnant within the past year _,_ Cl YES 47 nrD
<br />a=
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<br />22e. DATE OF INJURY (MO.,,Dey, Yr.) 226. TIME OF INJURY 220. PLACE OF INJURY•At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />... __J2U I .. _ ._.._.... _...._
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<br />22d. INJURY AT WORK?
<br />22e, DESCRIBE HOW INJURY OCCURRED _
<br />23d. To the best of my know (lge, death occurred at the lime, dale and place
<br />to the caus s)'ed. ( Signature a Title ) ♦
<br />')
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<br />24e. On the basis of examination and/or invesilgatlon, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Tllle) r
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<br />❑VES �S
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<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT, NO. CITYlTOWN STATE ZIP CODE
<br />25. DID TOBACCO S CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? t;b, WA5 CONSENT GRANTED?
<br />L.1 VES ❑ _110 Cl PROBABLY ❑ UNKNOWN ❑ YES 210 Applicable if 26a is NO ❑ YES �O
<br />27. NAME, TITLE A.,... - -- -- --• _. _....
<br />ND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER' PHYSICIANOR COUNTY ATTORNEY) (Type orPrint)
<br />Dr Ryan D Crouch DO 800 Aloha
<br />28a. REGISTRAR'S SIGNATURE 2ab. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />23a. DATE OF DEATH (Mo., Day, Yr,)
<br />24a. DATE SIGNED (Mo,, Day, Yr.)
<br />24b. TIME OF DEATH
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<br />-0 E3
<br />&N
<br />December ].J , ?_0..06
<br />Day, Yr.)
<br />a�_=
<br />-
<br />24c.PRONOUNCEDDEAD(Mo.,Day,Yr.)
<br />24d.TIME PRONOUNCED DEAD
<br />23aTIMEOFDEATH
<br />23b.DATESIGNED(Mo.,
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<br />December J 1 , 200
<br />7.45 rn
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<br />23d. To the best of my know (lge, death occurred at the lime, dale and place
<br />to the caus s)'ed. ( Signature a Title ) ♦
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<br />24e. On the basis of examination and/or invesilgatlon, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Tllle) r
<br />,
<br />c°) `o
<br />25. DID TOBACCO S CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? t;b, WA5 CONSENT GRANTED?
<br />L.1 VES ❑ _110 Cl PROBABLY ❑ UNKNOWN ❑ YES 210 Applicable if 26a is NO ❑ YES �O
<br />27. NAME, TITLE A.,... - -- -- --• _. _....
<br />ND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER' PHYSICIANOR COUNTY ATTORNEY) (Type orPrint)
<br />Dr Ryan D Crouch DO 800 Aloha
<br />28a. REGISTRAR'S SIGNATURE 2ab. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />
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