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<br />~
<br />
<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH"AN!Y1#MlW$ERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIG/~-!JJ!'9l{Fit:f,wrtH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAt/fH{O$.~Wt!1C,1;! IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. =i=..~'-t~'o=l.~= tf!i::x...~~~.=-".'..-'~.'
<br />
<br />DATE OF ISSUANCE.fIJ" .~" ~"
<br />DEe 0 5 2006 20070579 4 .~t'?~: '-'NtJ~S,c~_"'~O$
<br />w A~sTA!jf ~.' i4t~ji "!ismMl
<br />LINCOLN, NEBRASKA HEAIJfHA ': ERVIC6$
<br />'~-,-~~\:.c~~"'f<f~~;'\)
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCEAPiEf-SU!'J'9.Rft-'--6' 3. _..19 O. 6.
<br />H______ .. CERTIFICATE._9F DEATH _.,.'...u .
<br />
<br />DECEDENT'S.NAME (Flrsl,
<br />Phyllis
<br />
<br />Middle,
<br />J_n~!"ln
<br />
<br />last,
<br />
<br />Suflix)
<br />
<br />2.SEX
<br />FemaJ,e
<br />
<br />3. DATE OF DEATH (Mo" Dey, Yr.)
<br />
<br />October 14, 2.QQL
<br />
<br />6. DAn, OF BIRTH (Mo" Day, Yr.)
<br />
<br />Loup City, Nebraska
<br />
<br />
<br />5e, AGE.Lasl Birthday
<br />(Yrs.)
<br />74
<br />
<br />Jun,:_ 26,. 1~3.2
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />507-38-6659
<br />
<br />8a, PLACE OF DEATH
<br />~: 0 Inpallent
<br />
<br />QlliE8: U Nursing Home/LTC U Hospioe Facility
<br />
<br />(II nol institution, give streel and number)
<br />
<br />o ER/Outpellenl
<br />
<br />~ Decedent's Home
<br />
<br />Gt'and Island
<br />9a, RESIDENCE-STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />2540 North Webb Road
<br />
<br />_ leb' CO~;. .~~
<br />
<br />--- ..--
<br />
<br />o U)\ 0 Olhar (SpecifY)_n
<br />
<br />~UNTY OF DEATH
<br />Hall
<br />~- ,.".._.~
<br />
<br />2540 North Webb Road
<br />
<br />Bc, CITY OR TOWN OF DEATH (InclUde Zip Code)
<br />
<br />------
<br />10a, MARITAL STATUS AT TIME OF DEATH Il!i Married 0 Never Married
<br />
<br />9c. CITY OR TOWN
<br />Grand Island
<br />
<br />==t~..AnNoL:~O;~~n_
<br />
<br />lOb, NAME OF SPOUSE (Firsl, Middle, Lasl, Suffix) II wife, give maiden name,
<br />
<br />9g, INSIDE CITY LIMITS
<br />Q[ YES U NO
<br />
<br />o Divorced 0 Unknown
<br />
<br />Jerome Rewolinski
<br />
<br />11. FATHER'S.NAME (Flrsl, Middle, Lest,
<br />Seth F. Carmody
<br />13. EVER IN .U. 'S.. ARMED ~ORCES? Give dale~ ~f~';;-;i~; if yes. LINFORMANT.NAME---
<br />(Yes,nn,orunk.) No Jerome Rewolinski
<br />15,METHODOFDISPOSITION rBa MBALMER.SIGNATURE ~
<br />
<br />:::'00 ~ ::::.."" ""m~ c",~E ,""",",oc^,,,,- .
<br />
<br />
<br />o Removal [J Olher (Spoclfy)
<br />Grand Island City Cemetery, Grand Island, Nebraska
<br />
<br />17e, FUNERAL HOME NAME AND MAILING ADDRESS (Slree;, City or Town, Stale)
<br />
<br />Liviingston-Sondermann Funeral Home, 601 N. Webb Rd., Grand
<br />
<br />;
<br />
<br />Sulfix)
<br />
<br />12. MOTHE'R'S.NAME' (First,
<br />Lenora
<br />
<br />Mlddla,
<br />
<br />Malden Surname)
<br />Brooks
<br />
<br />14b. REOLATIONSHIP TO DECEDENT
<br />Husband
<br />
<br />1143
<br />
<br />16c. DATE (Mo., Day, Yr,)
<br />October z,g, 2006
<br />
<br />1 Bb, LICENSE' NO,
<br />
<br />CITY /TOWN
<br />
<br />STATE
<br />
<br />PART I. Enter the chain or event,~,--dlsaasesr InjurIes, or cornpllcallonsuthat directly caused the death, DO NOT enter terminal events such as oardlac arrest,
<br />resplralory a"esl, or venlrlculer librlllatlon wilhoulshowlng the eliology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additlonellines If necessary,
<br />IMMEDIATE CAUSE;
<br />
<br />
<br />IMMEDIATE CAUSE (Final
<br />dIsease or condition resulting
<br />In death)
<br />
<br />~ Congestive Heart Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I
<br />: fset to death
<br />
<br />I Immediate
<br />.L,_
<br />I onsello death
<br />I
<br />I
<br />I Years
<br />
<br />I onset 10 dealh
<br />I
<br />I
<br />1..,. n._
<br />j onset to death
<br />
<br />SaquenUally list condition., if (b) Increasin~ckage of the Arteri es
<br />any, leading to the cau.a listed DUE TO, OF1AS A CONSEQUENCE OF: --
<br />on line a.
<br />Enter the UNDgRLYING CAUSE
<br />(dl..... or Injury that Initieted (cl
<br />the events resulllng In d.ath) DUE TO, OR AS A CONSEQUgNCE OF;
<br />I.AS1'
<br />
<br />(dl
<br />PART II, OTHER SIGNIFICANT CONDITIONS.Conditions conlribuling 10 Ihe dealh but not resulting in Ihe underlying caus. 91ven In PART '- --[jAB MEDICAL EXAMINER "
<br />OR CORONER CONTACTED?
<br />~ YES 0 NO
<br />-, -~-
<br />~ IF FEMALE; ~ MANNER OF DEATH 2)1aFTRANSPORTATION INJURY .JIG. WAS AN AUTOPSY PERFORMED?
<br />
<br />~ Nol pregnant wilhin pas I yeer Ii4 Natural 0 Homicide 0 Driver/Operator
<br />o Pass.nger 0 YES Xl NO
<br />o Pregnant al timo of d.alh I.J AccidentO Pendln9lnv.otlgellon
<br />U Pedoslrian
<br />o Not pregnallt, bUI pregnanl within 42 days 01 dealh 0 Suicide U Could nol bo delermined jid' WERE AUTOPSY FINDINGS AVAILABLE TO
<br />'5! ' 0 Olher (Specity)
<br />ij' 0 NOI pregnanl, bul pregnanl43 days 10 1 yo., before d.alh COMPLETE CAUSE OF DEATH?
<br />
<br />,:~ __Cl Unk~~wnIIPregnanlwilhinlh.paSI~ear _.__n._. .n._... [J YES . ..:if'NO
<br />
<br />,,:8: 22a. DATE DF INJURY (Mo" Day, Yr.) rF INJUR: -! 22c. PLACE OF INJURY.AI home, farm, Slreel, factory, ollice building, conslruction sil., el~: (~peCilY)
<br />
<br />
<br />~t, 22d.INJURY ATWO~RK? - m._ 22.. DESCRIBEHC;W INJURY OCCURRED" ---
<br />""'\
<br />, 0 YES 0 NO
<br />--- -- ---
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO. CITY/TDWN STATE ZIP CODE
<br />
<br />
<br />m
<br />
<br />
<br />n .
<br />~TIME OF DEATH between
<br />6 : 40 am & 7: 00 a m
<br />
<br />ptJ. TIME PRONOUNCED DEAD
<br />m
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 14, 2006
<br />
<br />z>-
<br />~~~
<br />~~~
<br />c.ifiC(~
<br />E .."~ z
<br />8ffizO
<br />li~5
<br />~~~
<br />uo
<br />
<br />-fi.OiDTOBACCOUSE CONTRIBUTE TO THE DEATH? ~ HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />DYE'S 0 NO 0 PROBABLY XI UNKNOWN U YES .q( NO Not ApJ'llceble il2Ba is N?.o YES 0 NO
<br />
<br />~~~h~:: Art4D~A~Y~~C~R:IFlge(~H~~~AN':C~~~~Et'~PHAStt~~~~~:YA23RIEy~(:y~r~;~ts t Street, Grand Is 1 and, NE 68 02
<br />
<br />23b, DATE SIGNoD (Mo., Day, Yr,)
<br />
<br />23c. TIME OF DEATH
<br />
<br />23d. To !he beSI 01 my knowledge, dea1h occurred at Ihe time, date and place
<br />and du.IO Ihe ceuse(s) staled. (SignelUre end Tillo) "
<br />
<br />. On Ihe basis of examination Md/or Investigation, In my opinion death occurred at
<br />Ihelime, dalo and place end due to the ceuse(,) stated. (Signature and Tille) "
<br />
<br />28a. RWISTRAR'S SIGNATURE 2Bb. DArE FILED BY REGISTRAR (Mo" Day, Yr,)
<br />
<br />
<br />NOV
<br />
<br />3 2006
<br />
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