|
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAl. OF THE NEBRASKA HEALTH AND HUM~_,,!~E~VICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A tRUE COpy OF THE ORIGINAL RECQ~H
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTlCS:~9TtlJlff.'W#$fi.ff'~~
<br />
<br />:::;::~~:::::;TORY FOR VITAL RECORDS'IVh1!~~f!-~I!if~~:.':~'___
<br />
<br />JJVf"' ~""'iJTANt.EY S. -"G.OOf'ER
<br />OCT 2 3 2006 ASS/STcANT.STATE REG/STRifE!:
<br />LINCOLN, NEBRASKA 200703128 HEALTH'it.ND in!~N,~ptS-
<br />
<br />
<br />
<br />':" ~---
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE: AND SUPPORjli 6
<br />.. "'_ ...._CERTIFIC~TE OF DI;~IH ___ U ..
<br />
<br />31047
<br />
<br />1. DEC~D~NT'S-NAME (Flrsl, Middle, Last, Suffix)
<br />Rosalie (aka Rose) Dey Ermand
<br />
<br />- '"'' '" ,;,;;0","" "",. ,. CO" "" co,,;;'" " "'"'" I ,; ""., "'''"'. ". "" '" , "'"
<br />(Yrs ) MOS. DAYS
<br />
<br />Reyn~~ds, Neb_raska _ 74 _
<br />
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />
<br />2. SEX
<br />Female
<br />
<br />3. DATE OF D~ATH (Mo., Day, Yr.)
<br />October 9. 2006
<br />
<br />5e, UNDER 1 DAY
<br />HDURS MINS,
<br />
<br />6, DATE OF BIRTH (Mo.. Day, Yr,)
<br />
<br />February 18, 1932
<br />
<br />507-40-1800
<br />
<br />lillSf'.ITAL:
<br />
<br />OIlnpatlenl
<br />
<br />QlliEB: 0 Nursing Home/LTC 0 Hospice Facility
<br />
<br />8b. FACILITY-NAME (If nol instllutlon, give street and number)
<br />
<br />Ll ~R/Oulpalient
<br />
<br />o Decedant's Home
<br />
<br />St. Francis Medical Center
<br />
<br />'~1Y.".'-
<br />~~l
<br />'". --
<br />
<br />w CO\ 0 Olher (Specify)_
<br />-~UNTYOF~
<br />____~Hal1
<br />'-'~YORTOWN -
<br />~ Grand Island
<br />
<br />-- ~ ge APT NO [~f' ~ ;~~ 1
<br />
<br />10b. NAME OF SPOUSE (Firsl, Middle, Lasl, Suffix) ff wife, 91ve maiden name.
<br />
<br />9g. INSIDE CITY LIMITS
<br />m YES 0 NO
<br />
<br />9d, STREET AND NUMBER
<br />2421 Commerce
<br />1 Oa. MARITAL STATUS AT TIME OF'DEATH f4(Morrled 0 Never Marriod
<br />
<br />o Marrlod, bUI separaled 0 Widowed 0 Dlvorcod U Unknown
<br />
<br />11, FATHER'S.NAME (Firsl,
<br />Henry John Ross
<br />
<br />Middlo,
<br />
<br />Last)
<br />
<br />Dale J. Dey, 'El1mand
<br />
<br />SUffix) L2~~;;:R;-NS~~~Fir~~Vingto~ddl'0:
<br />
<br />Malden Surneme)
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dales of servico if yes.
<br />(Yes, no, or unk,) No
<br />15. METHOD OF DISPOSITION
<br />ill: Burial 0 Donolion
<br />
<br />o Removal
<br />
<br />o Other (Specify)
<br />
<br />14a, INFORMANT-NAME
<br />Dale J. DeyErmand
<br />
<br />16~~M~~T;0 ~~~ I~b1L~~N;~NO'"
<br />
<br />16d. CEMET~RY, CREMAT~THER LOC~ CITY / TOWN
<br />
<br />
<br />Westlawn Memorial Park Cemetery, Grand Island
<br />
<br />14b. RELATIONSHIP TODEC~DENT
<br />Husband
<br />
<br />o Cremallon 0 Enlombmenl
<br />
<br />16c. DATE (Mo" Day, Yr. )
<br />
<br />October 12, 2006
<br />
<br />STATE
<br />
<br />17.. FUN mAL HOME NAME AND MAILING ADDRESS (Street, Cily or Town, Sial e)
<br />Livingston-Sondermann Funeral Home,
<br />
<br />PAR r l. Enter the ~,llt.~--diseases, InJuries, Or complications--thal dIrectly caused the death. DO NOT enter termInal events such as cardiac arrest.
<br />rospiralory atreSI, or venlricular flbrlllaUon without showing Ihe ellology. DO NOT ABBREVIATE. Enler only one caUse on a lino. Add addlllonallines if nocessary,
<br />
<br />20, IF FEMALE: 21a, M~NER OF DEATH
<br />.-L" ,.2] Natural 0 Homicide
<br />."Jti!J Not pregnant within past year
<br />
<br />o Pregnant a1l1me of dealh 0 Accldenl 0 Pendinglnve.llgallon
<br />o Pedestrian
<br />o NOI pregnanl, but pregnanl wllhln 42 days of dealh 0 Suicide 0 Could nol be determined 21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Olher (Spocify)
<br />LJ Not pregnanl, bUI pregnanl43 days 10 1 year before dealh W Q 0/ P IV (l. ,11 COMPLET~ CAUSE OF DEATH?
<br />
<br />o Unknown il pregnanl wllhin Ihe pasl yoar \-jltf Ill\ 0 Y~S 0 NO
<br />
<br />22a DAT~ OF NURj (M~ ' Day, Y~2b- TI~ J ~AR~ 22c PLACE OF 1~=rrt~3el' factory, olliee building, construction 611e, ete (Spoclfy)
<br />
<br />
<br />22d INJURY ATWOR~ 22e DESCRIB~ HOW INJU Y OCCURR~D
<br />DYES crNO
<br />
<br />I
<br />I
<br />
<br />I onsello dealh
<br />
<br />~rf ~
<br />
<br />I onselto dealh
<br />
<br />(b) ,Ct;:jZ,t;i?ro VQlt eN! lI4-fL -PC c';IDEN/ JI
<br />Soquontlally list conditions, If ~ 10
<br />
<br />~~:l~~:::~~::hL::~::~:::d DUETO~~~~E~ENC~~p-- y11~ I 0 C -DlYl.6\I P b rr 1_ltrllJ1)) : ~.2." .~
<br />
<br />(disease or Injury that initiated (c). . ,.
<br />Ihe eventsresulllng In death) DUE TO, OR AS A CONSEQUENC~ OF: -- '-.. I onsello dealh I
<br />
<br />~'m" "",""i"""^,;:,,tJI~~~~,:"~~" ,.1. o;~ ~~~.~~~.. "'"'''''"" """ ".'" co """ -::: ~:~AA"'''"
<br />
<br />HY~ y.<. L Wfrn MI A OR CORONER CON)>6fED?
<br />{ 11"1"\ 0 Y~S ~O
<br />2;~O~ INjURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operalor
<br />o Passenger
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />in death)
<br />
<br />(a)
<br />
<br />iMMEDIATE CAUS~:
<br />
<br />Q.,-~ J2.t1! O'RFIf pn-O -rOPy
<br />
<br />Q It 9fr
<br />
<br />JOb
<br />
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />DYES
<br />
<br />~/
<br />
<br />
<br />22f. LOCATION OF INdURY - STREET & NUMB~R, APT. NO,
<br />
<br />STA~
<br />
<br />ZIP CODE
<br />
<br />24a, OATE SIGNED (Mo., Day, Yr.)
<br />
<br />_exJ-- , D ~ OC)f2
<br />
<br />240, PRO OUNCED DEAD (Mo" Dey, Yr,)
<br />.'
<br />
<br />:4:~JF lfTH A m
<br />
<br />24d. TIM~ PRONOUNCED YD m
<br />
<br />",_~Ol Applicable If 26a i~_NO 0 ns U NO
<br />
<br />2Ba. R~GISTRAR'S SIGNATlJR~
<br />
<br />Grand Island, NE 68801-732
<br />2Bb. DAT~ FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />~
<br />
<br />OCT 1 2 2006
<br />
|