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<br />~
<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTHAND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BEA TRUE COpy OF THE ORIGINAL REC'!fl-R 9P{f{4E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSTlc.~qrLp!l,.~.IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. .M.JJ;~ i""'-;~iA,\
<br />
<br />DATE OF ISSUANCE JV"'-r"Jf,~y !l ~~~~
<br />
<br />APR 1 8 2007 20070 AI 2 68 ASSI$TANJ STAtE a&:I$T~AR ;-:
<br />LINCOLN, NEBRASKA 't HEALif1ANQ. HLlMAN SERV}CE~:;
<br />
<br />
<br />-~-- ~ ~"'~'. ~_.-
<br />S.TATEOF...NEBRASKA-D...E PARTMENT.. .0. FHEALTHANDHUMA..NSERVICESFiM~riC~;o;N.. ',,~S.'.~~7 .. 2..39 t:: 1
<br />-- ._.__~EBTIFICAT_E OF DEATH . '.- '::::-':~~~ . .' 01.+
<br />
<br />1. DECEDENT'S.NAME (Firsl, Middle, Lasl, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />__.._~o_~e_ ~_ ~iggs Male March 24.2007
<br />
<br />, "tt ." """ ""'",m~ " co,,,,, """~ " ""'" l' "',., ",,'""- .., ",om, "" " ""m , M' " M" " ""'" '" "" "I
<br />(Yrs) MOS r DAYS HOURS MINS.
<br />
<br />Brewster. Nebraska 93 Jan. 17. 1914
<br />
<br />7. SOCIAL SECURITY-NUMBER f- 8e PLAC~OF;;E~
<br />
<br />723-03-25_6.~.____.___._. JjQffjJ/lL LJ Inpatlenl illHER:. Nursing Home/LTC UHospiceFacilily
<br />
<br />8b. FACILITY.NAME (II nol InSlilution, [lIve straet and number) U ER/Ouipatlent 0 Decedant'. Home
<br />
<br />Linden Court u LO\ DOlher(Specify)
<br />8c.CITYORTOWNOFDEii;:H'(lnCIUdeZipc~' --- -~- ------rsd COUNTY OF DEATH
<br />~r~h Pla_~~-=--__ ""'.. 6910_~__ _L Lincoln
<br />ga.RESIDF.NCE.STATE ~b.c6.UNTY.. ~ClTYORTOWN --
<br />Nebraska~Lincoln__~ North Platte
<br />9d. STRE~T'AND. N. UMBF.R"--"-. . -- ... .--,. - -"~e-A~gL ZiP CODE..... ~.. ...99INSIDF. CITY Lt.MITS
<br />__}700 West Ph~llip _A~enue._ __L __1 69101_ _I III YF.S 0 NO
<br />10.. MARITAL STATUS AT TIME OF DEATH . Married 0 Nevar Married lOb. NAME OF SPOUSE (First, Middle. Lest, Suffix) II wite, give maiden neme.
<br />
<br />
<br />o Married, bul separaled 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Alice:Bonde
<br />ll-FA:r;:iER-;S:-NAM~~-- ------;';-'ifdle, Lasl,' ~'12:-MorHER'S'NAME (First, Mldd;~:-' Malden Surnama)
<br />__ Por:teE.._ C. Ri~gs __ _~. _ ~a~garet _Adel1au_~binault
<br />13 EVER IN U S ARMED FORCES? Give dales 01 sorvle.~ 4a INFORMANT"NAME
<br />(Yes,no,orunk) No ----1 Janet Rodocker
<br />~THOD OF DISP~SITI~ 16a EMB^L~:.~. - NATURE- ~ ~ ) /" ~ICENSE NO
<br />BBurial o Donalion ~~""'~~ __J~9 ____.
<br />o Cremalion 0 Enlombmenl 16d CEMjJ.5-R'f. CREMATORY OR OTHER LOCATION CITY / TOWN
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Da_ughtel:".__
<br />
<br />16c. DATE (Mo., Day, Yr.)
<br />March 28. 2007
<br />
<br />STATE
<br />
<br />o Removal 0 Olher (Specily)
<br />
<br />Brewster Cemetery
<br />- ._""~._._--'"._,_.__...- ,--.. --.-..
<br />17a. FUN~RAL HOME NAME AND MAILING ADDRESS (Street, Clly orTown, Slete)
<br />Carpenter Memorial Chapel. 1616 West B Street.
<br />
<br />Brewster
<br />
<br />Nebraska
<br />
<br />~s. PAR i I. Eiltor the !Jla1J.! .Q.tlity~~..dl.seases, injuries, or complicalionS--lhat directly crl.used the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT AB8REVIATE. Enler only one causa on a line. Add addiUonalllnes If necessary.
<br />
<br />
<br />APPROXIMATE INTERVAl
<br />
<br />(e)
<br />
<br />A/f;"'-..t!~'1.J ~-<~-<<
<br />
<br />I
<br />I
<br />
<br />I onsat 10 death
<br />
<br />: b~~
<br />
<br />I
<br />I on,et 10 dealh
<br />
<br />: I wIL
<br />
<br />----"--------
<br />I Onsst to death
<br />I
<br />I
<br />-----L.._. __
<br />I onset 10 dealh
<br />I
<br />I
<br />
<br />IMMEDIAT~ CAUSE:
<br />
<br />IMMEDlA rg CAUSE (Final
<br />dIsease Or condition resulting
<br />In death)
<br />
<br />~.4L~
<br />
<br />DUE TO, OR AS A CONSEQUF.NCE OF:
<br />
<br />dt:~te~~r
<br />
<br />(b)
<br />
<br />
<br />Sequentially lis. conditions, If
<br />any,l~adlnQ to the cause listed
<br />on linea.
<br />Enler the UNDERLYING CAUSE
<br />(dlaea.e or Injury that Initiated
<br />the events resulting In death)
<br />lA'>r
<br />
<br />DUF. TO, OR AS A CONSEQUENCF. OF:
<br />
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />(d)
<br />
<br />--18. PART 11~'OTHm SIGNIFICANT C()NDITIONS'C~~dllion' conlrlbullng 10 Ihe death but nol rcsulllng In Ihe underlying causa given in PA~--- ]J19. ~AS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />o YES ~.
<br />'.--.'.-...---.- .'-'..-. --..- --~"...._- .. ..-...--
<br />21 b.IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />(J Driver/Operator
<br />
<br />20. IF FEMALE:
<br />
<br />21a. MANNER OF DEATH
<br />l.il1lalural L.J Homicide
<br />
<br />
<br />U NOI pregnant within past year
<br />U Pregnantalllme 01 dealh LJ AccldenlD Pending Invesligatlon (] Passenger
<br />
<br />o Nol pregnanl, but pregnanl wilhin 42 day' 01 dealh 0 Suicide 0 Could nol be delermined 0 Pedestrian 21d. WERE AUTOPSY FINDINGS AVAilABLE TO
<br />':~ U NOI pregnanl, bUI pregnanl43 day. 10 1 year before daalll U Olher (Specity) COMPLeTE CAUSE OF DF.ATH?
<br />. ."'. 0 Unknown II pregnanl within Ihe pasl ycar LJ YES U NO
<br />:~i. 22-~.'DA-j-E-'OF INJU'RY (M~~Day, Yr.) ,.. '.. !22b. TIME 'OF I'NJU/W 22~-PLACE OF iNJURY.AI hooi;;;;;m, str.et, 'aclory, office building, conslru~li~~ site, etc. (Spe~iIY'------
<br />
<br />die l-~8~~___ "_ I Unk, In Nursing Home -
<br />22d INJURY ATWORK?T2e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />U YES iXNO Fell "
<br />-- - -- -- ---- --
<br />22f. LOCATION OF INJURY. STREET & NUMOF.R, APT. NO.
<br />
<br />DYES
<br />
<br />I]h<ffi"
<br />
<br />CITY/fOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />_~ __4000 W. Philip.
<br />23a. UATE OF DEATH (Mo., Day, Yr.)
<br />March 24. 2007
<br />23b. DATE SIGNED (Mo.. Day. Yr.)
<br />Ifrl.(7
<br />
<br />__~~Jh Platte_. N~___
<br />24a. DATF. SIGNED (Mo., Day, Yr.)
<br />
<br />69101
<br />
<br />23c. TIM~F DEA~
<br />!. . .,(.
<br />,_). ( . m
<br />
<br />Z>
<br />$~~
<br />smg;
<br />,,~I:
<br />D.ll.~~
<br />E"'~Z
<br />OD: 0
<br /><Ow
<br />J;z=>
<br />00
<br />~c:O
<br />o ~
<br />'-' 0
<br />
<br />24b. TIMF OF nFATH
<br />
<br />m
<br />
<br />IJJI.... DOf'"lI\lf"lt It\l~i=n nl=ll,n 1M/) n~V, Yr.)
<br />
<br />24d, TIME PRnNtlllhl,;J:n /Ii:An
<br />
<br />m
<br />
<br />23d. To tho bast of my knowledge, dealh occurred atlhe time, dale and place
<br />and dUt'~h: cause(s) Slalef-,~"e ~nd Tilla)... .
<br />
<br />(>JO'-"y" ?41-li.,
<br />
<br />248. On tba basis of examination and/or invBstigation, In my opinion deatll occurred at
<br />Ihelime, dale and place anll due 10 Ihe cause(s) staled. (Signature and Tille) ...
<br />
<br />~5. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDF.RED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />DYES 1..Il"If6 0 PROBABLY 0 UNKNOWN 0 YES ~~. NOI Applicable 1126. is NO
<br />27. NAME. TITLE AND ADDRESS OF CEFHIFiER (pHYsi6IAN~ CORONER'S PHYSICIAN OR'COUNTY ATTORNEY)iType or P'inJl . --.-
<br />Douglas States, M.D.. 209 McNeel Lane. North Platte. Nebraska 69101
<br />
<br />DYES U NO
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />APR
<br />
<br />9 2007
<br />
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