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<br />STATE OF NEBRASKA ,r_,,\
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<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND/fOM.AN SERVICES
<br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RFCgRI?_Q1J-~1f.~__WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSTlC~~~]}l~l(, .~Hf!J!1",-IS
<br />
<br />::~:::::~:;RY FOR YITAL RECOROS. ~~E~~~l
<br />APR 0 9 ZOOl 20 0 7 0 3 5 0 5 ASSISTANt siAiE=Fifuisf"RA'R,-,:
<br />HEAL THANiJ .,!U~AN SERV~~ESt'
<br />
<br />LINCOLN, NEBRASKA
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<br />~
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<br />. - - ___ ...n~. _... _
<br />~~~~ ":~.:'~.:~'~ ~~~~'.:~:~;~:
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINAiilcEAf:'ltlStlPJ'>ORT -
<br />_______~.~TIFICATE Of;-DEATt'-___,OJ23-8DL
<br />
<br />1. DECEDE:NT'S-NAME (Flrsl, Middle, Lasl, Surtlx) 2. SEX 3_ DATE OF DEATH (Mo., D.y, Yr,)
<br />Bethel Eleanor Gordon Female March 31, 2007
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<br />4, CITY AND STA.;E:. C;R TERRIT. O~."" CO"", ,,",;~.oc "'~"t.' A.G~-'l'SI Blrlh.d'~ ~.U.-.NDE:;;-;YEAR. . ___5C'-~-ND.E. R 1 DAY 6_ DATEO-F-BIRTH (M~~
<br />
<br />Hamilt~n County, Nebra~ _ _~Y"') 92_~Or HOURst MINS, November 16, 1914
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<br />
<br />7 SOCIAL SECURITY NUMBER f' PLACE OF DEATH "--"'-'--
<br />- _~98-18-5~__ ____ !::lQSEJIAl., Olnpallenl QllifB: 0 Nursing Home/LTC LJHospiceF.clllly
<br />8b FACILITY-NAME (If not Inslilutlon, give alreel .nd number) 0 ER/Oulpalienl IllI Decedent's Home
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<br />Home: 2706 Apache Road 0 [)}\ OOlher(Specily)___,._
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<br />8c'-CITY OR TOWN OF~ATH (Includ. Zl~-- J:OUNHTYa01FDlEATH --- ---
<br />Grand Island 68801
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<br />:~9'R~I:~~E::~~~~lgb'COU~all -~IT;;~~~ Isla~-;---
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<br />9d, STREET AND NUMBER - , =r" APT NO gl ZIP COP~ ~g_ INSIDE CITY LiM... ITS
<br />2706 Apache Road 6880 1 ~ YE:8 Cl NO
<br />--",- ~.- -- --~.," -., ~,-~
<br />10., MARITAL STATUS ATTIME OF DEATH 0 Married 0 N.ver Marrl.d 10b, NAME; OF SPOUSE (Flrsl, Mlddl., Lasl, Suffix) If wil., give m.id.n n.me,
<br />
<br />o Married, bUl separated 01 Widowed Q Divorced Q Unknown
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<br />;~:-FATHER'8~;AME J:~~-~- F~j\on 8ufflx) ! ;2 MOTHER;;;.NAME (F~~;:::--~~'--~~hn~;n.m.)
<br />
<br />;3 EVER IN-U S ARMED F~RCES? GIV; dal.s of s.rvlc~; INFORMANT.NAME - . -- - -;4b, RELATIONSHIP TO D~(;EDENT
<br />
<br />-:;'~;:':;:;":,""'-f'"~';"~'''' Craig wanamakerr 16b L1C~NS~ -- 16c, OAT:::' D.y, Yr,)
<br />
<br />08uriol ClDonellon Not Embalmed April 2, 2007
<br />----~-----~ "'-".-
<br />~Cr.m.llon 0 Enlombment 16d CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />
<br />
<br />oR.moval OOlh.r(SpeClly) Westlawn Memorial Park Crematory Grand Island, NE
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<br />~..- -~~-- ""--"'..
<br />17., FUNERAL HOME NAME AND MAILING ADDRESS (Slr.el, Cily or Town, Sial.)
<br />
<br />Apfel Funeral HOme 1123 West Second
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<br />PART I. Enl.r Ihe chain 01 .v.nls--dis"s,s, Injuries, or complic.lions'-Ihat dir,clly c.used Ih. d.alh. DO NOT .nler lermln.l.venl. such 'S cardl.c arr.sl,
<br />respiralory .rr.sl, or v.ntrlcul.r fibrlllallon wilhoutshowing the etlology_ DO NOT AB8REVIATE, Enl.r only one caus. on . line, Add additlonallin., il n.cessery.
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />dl..... or condlllon re.ultln9
<br />In death)
<br />
<br />(.)
<br />
<br />heart attack
<br />
<br />I
<br />I
<br />
<br />! onset to death
<br />I
<br />I immedi ate
<br />_------L _____
<br />I ons.tlo d.ath
<br />I
<br />,
<br />"__, years ____
<br />I onset to death
<br />I
<br />I
<br />
<br />----~_._I_--._--._"
<br />I ons.tlo d..lh
<br />I
<br />'I
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />DUE TO, OR AS A CONSEQUENCE DF:
<br />
<br />S.qu.ntlalfylI.toondfllon.,II (b) arteri oscl eros i s
<br />any, feadlng to rhe c.u..If.I.d -----OUE TO, OR AS A CONSEQUENCE OF;..--------
<br />on linea.
<br />Enlerlh. UNDERLYING CAUSE
<br />(dl..... or Injury that Initiated (c)
<br />th..v.nlsr..ultlngln de.th) DUE TO:"OR AS A CONSEQUENiiO;;:----- -----~
<br />LAST
<br />
<br />(d)
<br />
<br />18_ PART II, DTHER SIGNIFICANT CONDITIONS-Condilions contribullng 10 Ih. d..lh bUI nol r.sulllng In the underlying oause glvsn In PART I.
<br />
<br />'__."_'J_~,_."__".,._,,._._~,___.
<br />
<br />1.-_.......-----
<br />t9, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />j/ll YES 0 NO
<br />".-..-...-
<br />21 c, WAS AN AUTOPSY PERFORMED?
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<br />20. IF FEMALE: 21a. MANNER OF DEATH 21b.IFTRANSPORTATION INJURY
<br />Xl: Nol pr.gn.nl wilhin p.st year UN.lurel 0 Homicide ODrlv.r/Operator
<br />o Pregn.nt atllm. of d..lh Cl Accld.ntO Pending Inv.stlg.tlon 0 P.ssenger 0 YES XIXl NO __..._
<br />o NOI pregn.nl, bUI pr.gn.nl wllhln 42 days 01 de.lh 0 Sulcld. 0 Could not b. d.lermlned 0 Pedestri.n 21d, WERE AUTOPSY FINDINGS AVAilABLE TO
<br />o NOI pregn.nt but pr.gn.nt43 dey' 10 1 year b.lor. death U Oth.r (Sp.clly) COMPLETE CAUSE OF DE:ATH?
<br />Cl Unknown II pregn.nl wllhln Ihe p.st yeer __,,_'-_,,_ 0 YES JO<NO
<br />22~ DATE OFlNJURY (MO_' D,Y:Yr'~~IME OF INJU~ PLACE -OF INJURY-AI hom., larm: Slre.t, I.clory, olfrc. bU~dlng, conslrU~lIon Sit., .Ie (Sp.cify) -
<br />
<br />220 INJURY ATWORKJ:ne DESCRIBE HOW INJURY OCCURRED - - -- - ---- -- --- --
<br />o YES 0 NO
<br />---- --
<br />----.------- -.-
<br />nl. lOCATION OF INJURY - STREET & NUMBER, APT. NO, CITYrrOWN STArE ZIP CODE
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<br />23., DATE OF DEATH (Mo., Day, Yr,)
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<br />23b, DATE SIGNED (Mo" Day, Yr,)
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<br />23c. TIME OF DE:ATH
<br />
<br />
<br />...~~
<br />.c~iE
<br />h~
<br />a,D..:..::( ~
<br />H~~
<br />.8~5
<br />~!fu
<br />o ~
<br />Uo
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<br />24~. DATE SIGNED (Mo., Day, Yr.) 24b,TIME OF D"EATHDe tween "~
<br />ApdJ3~7___. 000__.:- 050_Q~
<br />24c, PRONOUNCED DEAD (Mo" Day, Yr,)
<br />
<br />m
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<br />23d. To Ihe besl 01 my knowl.dge, dealh occurred .tlh. time, d.l. and place
<br />.nd due to Ih. causers) ,I.ted, (Slgn.lur'-and Tille) l'
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />_9"~~_Q PROBABL-"'-_--.9_~~KNOWN LJ Y~. _p<NO . Nol Appllcabl. i126.lsNO 0 YES D<NO__
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Pririi~
<br />Dean Elliott, Sergeant GIPD, 131 S.. Locust Street, Grand Island, NE 68801
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<br />28., REGISTRAR'S SI~NATURE
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<br />28b, DATE: FilED BY REGISTRAR (Mo_, D.y, Yr.)
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<br />APR
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<br />5 Z007
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