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<br />..
<br />
<br />STATE OF NEBRASKA
<br />
<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 ORIGINAL REC9!JPON-Fq.._E- WJTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTlCS._~~l!.,~"If~
<br />
<br />:::;::~::::::;TORY FOR VITAL RECORDS. MAfff..--.~~~~.~.7f.?'.~.:~.". ::e:.: ~:~~;~\_.'..~\~':
<br />""\IOW'~TliANi.1t~:cCWPEk-'_ '::~
<br />DEe 0 8 2006 2 0 0 70 3 5 3 0 ASSIS'f~t$TATEiiEGJstRAR- .
<br />LINCOLN, NEBRASKA HEALTH A.ND HutMpjSE.(fJt/~S-
<br />...' ." .., :"'::;": ~,~.~,7::::::.: -~...
<br />-.. .:::--<::....:'~. -
<br />
<br />"-
<br />
<br />\",
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<br />
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AN!15uPPORT
<br />CERTIFICATE OF DEATH -
<br />
<br />
<br />1. DECEDENTS-NAME (First, Middle, Lasl,
<br />Ivonne Vir inia Jalbert
<br />
<br />Sullix)
<br />
<br />2, SEX
<br />Female
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa, AGE-Lasl Blrlhday 5b, UNDER 1 YEAR
<br />(Yrs.1 MOS_ DAYS
<br />
<br />50, UNDER 1 DAY
<br />- , -.. ...- - ~~ _._~'" ..","'.'
<br />HOURS ,MINS,
<br />
<br />3, DATE OF DEATH (Mo_, Day, Yr.)
<br />
<br />Nov. 28, 2006
<br />
<br />B. DATE OF BIRTH (Mo_, Day, Yr.)
<br />
<br />[) e s ~lQ,t.D e S,__J:9.J'i'i!_______
<br />7, SOCIAL SECURITY NUMBER
<br />
<br />321-26-4948
<br />
<br />__,,].4
<br />8a, PLACE OF DEATH
<br />!:!QSElIAt
<br />
<br />Nov. 1 2
<br />
<br />1922
<br />
<br />xx Inpatient
<br />
<br />QJJ:!E8: 0 Nursing Home/LTC 0 Hospice Fecility
<br />
<br />8b, FACILITY-NAME (II nol Inslllullon, give streel and number)
<br />
<br />o ER/Outpatlenl
<br />
<br />o Decedent's Home
<br />
<br />st. Francis Medical ,Center
<br />
<br />DlXYI
<br />
<br />o Olher (SpecllYI"._",,,
<br />
<br />8e, CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />8d, COUNTY OF DEATH
<br />
<br />__Gr_Q._ud_ Island_ 68803 ~ -- I' - - Hall
<br />ga RESIDENCE-STATE 9b COUNTY 9c, CITY OR TOWN
<br />ska Hall Grand Island
<br />
<br />_._9~;T~_~~;_~N;:~~:___p_arLJ}Venue_m _ ___~__.__ _ _ _ 19~ :: NO g~Z;~ODE3
<br />
<br />.1qa. MARITAL STATUS ATT1ME qF QEATH 0 M::mled 0 Ne':'aI Married 11..1]. .nb' NAMl; OF SOOUSE-~Eir5t, Mlddi~1 L&st..S-uWx) I: wl~-Q:h"(l.n~~1-l naill-a.
<br />
<br />o Married, bUI 'eperaled Illi Widowed 0 Divorced 0 Unknown
<br />
<br />
<br />9g, INSIDE CITY LIMITS
<br />Kl YES C.I NO
<br />
<br />
<br />11, FATHER'S-NAME (Firsl.
<br />
<br />Middle,
<br />
<br />Lasl,
<br />
<br />12, MOTHER'S.NAME (Firsl,
<br />
<br />Middle,
<br />
<br />Melden Surneme)
<br />
<br />
<br />Conrad____
<br />14b, RELATIONSHIP TO DECEDENT
<br />
<br />o Burial 0 Donation
<br />Hi Cremation 0 Entombment
<br />
<br />Jud Kittel
<br />
<br />16:r5~~GI:AVE D a{~ /q
<br />
<br />16d. CEMETERY, CREMATORY OR OT " ER Loc~5-\
<br />
<br />
<br />(Yes, no, or unk,) no
<br />15, METHOD OF DISPOSITION
<br />
<br />16b, LICENSE NO_
<br />1071
<br />
<br />CITY /TOWN
<br />
<br />16c. DATE (Mo" Day, Yr, I
<br />Dec. 4, 2006
<br />
<br />STATE
<br />
<br />U Removal 0 Other (Speoily)
<br />Central Nebraska Cremation Service Gil::>.~~Nebraska
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slr.e\, City or Town, Slale) 17b, Zip Cod.
<br />
<br />All Fai ths Funeral Home 2929 S. Locust St. Grand Island, Nebraska
<br />
<br />
<br />
<br />18. PART I. Enter tho chain of evonis.-diseases, injuries, or complications--Ihat directly caused Ihe death. DO NOT enter (ermlnal evenls such as cardiac arrest,
<br />respiratory arrest, or ventrIcular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a linB. Add additional lines if necessary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onsel to dealh
<br />
<br />
<br />IMM~DIAT~ CAUS~ (Final
<br />disease or condition resulting
<br />in dealh)
<br />
<br />(a) . _Se.-,~::~~?_t~')~.,,~~~___
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I CJ......~. \"...,,,'v_..-,
<br />onsello death
<br />
<br />SequenU.lly list .ondllloos, If (bl
<br />any, leading 10 the .ause listed ~. TO, OR AS A CONSeQUeNCE OF:
<br />on line a.
<br />~nterthe UND~RLYING CAUS~
<br />(dls.as. or Injury thatlnltl.led (e)
<br />Ih@eventsresultlnglndeath)
<br />LAST
<br />
<br />onsel to deelh
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />ons.llo death
<br />
<br />(d)
<br />
<br />U ACCid8l1tU Pending :ilVa$U~:ion
<br />
<br />21b.IF TRANSPORTATION INJURY
<br />U Drlver/Operalor
<br />
<br />o peesangar
<br />
<br />o Pedeslrlan
<br />
<br />o Olh.r (Specify)
<br />
<br />r-19,WAS-MEDICAL EXA.. M....INER ......
<br />OR CORONER CONTACTED?
<br />DYES D-"NO
<br />~,'~",,"". _'n'..'...."'" _.
<br />210, WAS AN AUTOPSY PERFORMED?
<br />
<br />18, PART II, OTHER SIGNIFICANT CONDITIONS.Conditions conlribullng 10 Ihe dealh bul nol rosulling In Ihe undorlying cause given In PART I,
<br />
<br />;,: \} f')
<br />
<br />C 5, \,-.\"
<br />
<br />[)r"-~
<br />
<br />20. IF FEMALE:
<br />0"NOI pregnanl wilhln pasl year
<br />o Prognanl alllme 01 dealh
<br />U Not pregnenl, bul pregnant wilhln 42 days 01 deelh
<br />
<br />21a_ MANNER OF DEATH
<br />JJ'J;j~turel 0 Homicide
<br />
<br />U YES
<br />
<br />J.J-l'io'
<br />
<br />o Suicide U Could nol be delermlned
<br />
<br />21d_ WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />COMPLETE CAUSE OF DEATH?
<br />DYES '(,d"Ne;'
<br />
<br />'I
<br />
<br />l,.l,
<br />"
<br />III
<br />{i/.
<br />
<br />o Not pragnant, bul pregnant 43 days 10 1 year bofore d{)ath
<br />o Unknown if pregnant within the past year
<br />~2a, DATE OF INJURY (Mo" Dey, Yr.) I~~b' TIM~ OF INJUR:
<br />
<br />22d INJURY ATWOR~? ]22. DESCRIBE HOW INJURY OCCURRED
<br />o Y~S D.NO
<br />------ ---
<br />221, LOCATION OF INJURY - STREET & NUMBER, APT. NO,
<br />
<br />22c. PLACE OF INJURY-AI home, farm, street, factory, office building, Construction site, etc. (Specify)
<br />
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a, DAlE OF DEATH (Mo., Day, Yr.)
<br />November 28, 2006
<br />
<br />24a, DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b_l1ME OF DEATH
<br />
<br />am
<br />
<br />,.,n
<br />.cuz
<br />ll~g;
<br />uS~
<br />E"'>-Z
<br />8ffi!z0
<br />"Z'-"
<br />"'00
<br />t9c:::u
<br />O~
<br />uo
<br />
<br />m
<br />
<br />23b, DATE SIGNED (Mo" Day, Yr,)
<br />ecember 1, 2006
<br />
<br />
<br />240_ PRONOUNCED DEAD (Mo" Dey, Yr,1 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To the best of my knowledge, death occurred althe lime, dale and place
<br />end due 10 the causel'lsl.led, (Slgnalure end Tille IY
<br />
<br />24e. On the basis of examination and/or investigation, In my opinion death occurred al
<br />Iha time, dale and plac. and duelo Ihe causelsl staled, (Signa lUre and Tille) Y
<br />
<br />\ (j-<.J '1'v-"
<br />
<br />25. DID TOBACCO USE CONTRIBUTe TO THE DEATH?
<br />
<br />\.I.J<{ES U NO 0 PROBABLY U UNKNOWN U YES ',W,'fro.
<br />27, NAME:TiTLEiiNDADDRESS (JFCEFlTIFIEA (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Prinll
<br />
<br />
<br />,',> (.1
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />Nol !,-ppll_cable,lf26a i~_~()__ 0 YES C.I NO
<br />
<br />DEe
<br />
<br />6 200
<br />
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