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<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BEA TRUE COpy OF THE ORIGINAL RECORP.9N FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTlC%SE~-i'tJjICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. :J.P~:;fl;;;~--='2:"
<br />
<br />DATE DF ISSUANCE ~:~10.
<br />
<br />APR 2 3 2007 20 0 70 5 7 96 ASSISTANO:!AJ..E?lEgISIRAR
<br />LINCOLN, NEBRASKA " HEAl:.Tff-AND HUIIANSEFNlPI;S
<br />- .
<br />- __no
<br />~ . .---- ,~~. -. .
<br />- .'".,.. .~,-~~---
<br />.:,,-:_~ ~-::.:.~"f'E-~~~ "..
<br />
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FfNANCE -A.NEl SUR
<br />CERTIFICATE OF D!:ATH 'l. ,-" .
<br />
<br />;r
<br />
<br />2437L__
<br />
<br />
<br />1, D"C"D"NT'S-NAM" (First,
<br />Vera
<br />
<br />Middle,
<br />Berdeen
<br />
<br />Last,
<br />Hinkson
<br />
<br />Sullix)
<br />
<br />2.S"X
<br />Female
<br />
<br />3, DATE OF DEATH (Mo" Day, Yr,)
<br />April 12, 2007
<br />
<br />4, CITY AND STATE OR T"RRITORY, OR FOR"IGN COUNTRY OF BIRTH
<br />
<br />5a. AG".Last Birthday 5b, UNDER 1 YEAR
<br />(Yrs,) MOS. DAYS
<br />91
<br />
<br />5c, UNDER j DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />HOURS MINS,
<br />
<br />September 11, 1915
<br />
<br />Hall County, Nebraska
<br />
<br />7, SOCIAL SECURITY NUMB"R
<br />506-26-2001
<br />
<br />Ba. PLAC" OF D"ATH
<br />1J.Q.SflIAl:
<br />
<br />D Inpatient
<br />
<br />QllifB: :fu Nursing Home/LTC U Hospice Feclllty
<br />
<br />FACILITY-NAME (II not institution, give street and number)
<br />
<br />D ER/Outpallant
<br />
<br />o Decedent's Home
<br />
<br />Tiffany Square Care Center
<br />
<br />DCO\
<br />
<br />D Oth.r (Sp.cily)
<br />
<br />Bc, CITY OR TOWN OF D"ATH (Include Zip Code)
<br />
<br />Grand Island
<br />
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />
<br />68803
<br />9aR"SI::~;:T:ka _~__JOUNTY --~-~~l tC.CITYORTO;;and- IsI=:~
<br />9d,STRE:~A~D~:~~land Drive _ _m -.....- 1ge A;~NO 19f6Z;;~D; ___ _. ~_
<br />
<br />j Oa. MARITAL STATUS AT TIM" OF DEATH 0 Marrlad D Nevar Married rOb NAME OF SPOUSE (First, Mlddla, Last, Suffix) If wlfa, glva maiden name
<br />
<br />D Married, bul s.paroted III Widowed U Divorced D Unknown
<br />
<br />. n__' .,._~,~
<br />11. FATH"R'S.NAME (First, Middle, Lasl,
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />~ YES q NO
<br />
<br />Suffix)
<br />
<br />12, MOTHER'S-NAME (FIrst,
<br />Bertha
<br />
<br />Middle,
<br />
<br />Melden SUrnama)
<br />Pederson
<br />
<br />william
<br />
<br />Heupel
<br />
<br />13. EVER IN U.S, ARMW FORC"S? Give date, of ,ervice if yes. 14a.INFORMANT-NAME
<br />(Yos, no, orunk.) No Brian Hinkson
<br />
<br />j5':::r~a~OFDI~~:~::I:~ 16a.:!LMER-S~A~~ '. ..,--- -r~~;S-ENO'
<br />
<br />D Cremalion U Entombment 16d, CE~ CREMATOR;"~;;TH'ER LOCATION CITY / TOWN
<br />
<br />14b. RELATIONSHIP TO D"C"DENT
<br />Son
<br />
<br />16c, DATE (Mo., Day, Yr.)
<br />pril 16, 2007
<br />
<br />STATE
<br />
<br />D Removal D Oth.r (Sp.cily)
<br />
<br />Cameron Cemetery,
<br />
<br />Wood River, Nebraska
<br />
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City orTown, Stale)
<br />1123 West Second,
<br />
<br />PART I. Enter Ihe ~MW_o.f.!;!Y~.n1~:.dis8ages, InJuries, or compllcatlons--thal directly caused the death. DO NOT entef terminal events such as cardiac arrest,
<br />respiratory arre.t, or ventricular IIbrlllatlon without showing the etiology, DO NOT ABBREVIATE, Entar only one causa on a lina, Add additional line. If nac.ssary.
<br />IMMEDIATE CAUSE:
<br />
<br />(a) /lItr!UIlA ( (a <<~_~
<br />
<br />DU" TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />I tf,.I- !tt/1/;fe
<br />
<br />IMMEDIATE CAUSE (Flna'
<br />dl.ease or condition ...ultlng
<br />In death)
<br />
<br />onSet to death
<br />
<br />_~<:J...'!1.
<br />
<br />Sequ.ntlally lI.t condition., If
<br />any, leading to the c8usellsted
<br />on line a.
<br />Ent.r the UNDERLYING CAUSE
<br />(dl..... or Injury that Initiated
<br />th. .Vent. ...ultlng In death)
<br />lASI"
<br />
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF;
<br />
<br />onset to death
<br />
<br />H?'/VL
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on.atlo death
<br />
<br />(d)
<br />
<br />Jf/ rJ IV-
<br />
<br />lB. PART II. OTHE:R SIGNIFICANT CONDITIONS-Condltlona contributing 10 the death but nol r.sulting In tho und.rlying caus. giv.n In PART I.
<br />
<br />(' if hF'r;'(/<!,:4r~~~_[~:c
<br />
<br />20. IF FEMALE: 21a. MANNER OF DEATH
<br />o No! pregnant within pas I year ~alura.1 0 Homicide
<br />D Pregnant al tlma of dealh D Accid.nlD Pending Inv.stlgation
<br />D Not pregnant, but pregnant within 42 days of daath
<br />D Not pregnant, but pregnant 43 day' to 1 year b.for. d.ath
<br />o Unknown II pregnant within the past year
<br />
<br />19. WAS MEDICAL "XAMINER
<br />OR CORONER CONTACTED?
<br />
<br />D Y"S ~NO
<br />
<br />21b.IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />DYES
<br />
<br />j<NO
<br />
<br />D Passenger
<br />U Pedestrian
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES D NO
<br />
<br />o Suicide 0 Could nol ba determined
<br />
<br />D Othar (Spaclfy)
<br />
<br />22d, INJURY AT WORK?
<br />
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />22b. TIM" OF INJURY 22c, PLACE OF INJURY-At hom., farm, .tr..t, factory, offic. building, construction sil., elc. (Sp.cify)
<br />rn
<br />
<br />o YES 0 NO
<br />
<br />221. LOCATION OF INJURY. STR""T & NUMB"R, APT. NO,
<br />
<br />CITYITOWN
<br />
<br />SWE
<br />
<br />ZtP CODE
<br />
<br />24a, DATE SIGNED (Mo., Day, Yr,)
<br />
<br />24b. TIME OF DEATH
<br />
<br />!,~1:i
<br />'2~~
<br />H~
<br />a.11.:.x~
<br />f'""'~~
<br />8ffiz
<br />llz=>
<br />~~8
<br />O~
<br /><.>0
<br />
<br />2.t9" 7
<br />
<br />m
<br />
<br />23C. TIME OF DEATH
<br />1O 30 m
<br />
<br />24C. PRONOUNCED D"AD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />
<br />m
<br />
<br />23d. To the best 01 my knowledge, daath occurred allhe time, dete end piece
<br />and due to the cau.e(s) .tat.d, (Slgnatu and Titl.) '"
<br />"
<br />
<br />24a, On the besla of examlnallon end/or Investigation, In my opinion deeth occurred at
<br />th.lime, dale and place and du.to the cau,.(s) stal.d. (Signature .nd Tltla) ,.
<br />
<br />2Ba. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />_~~..2....__LJ PROBABLY... .... U._~NKNOW.N__ ___9 YES i'l NO___._ N~t_ ~~~I!.:.a~I.!.If. 2B!,...!.:!".~__~~---.B. NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Gary Settje M.D. 2116 w. Faidley #400, Grand Island, NE. 68803
<br />
<br />2Ba. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b, DATE FILED BY REGISTRAR (Mo" Day, Yr,)
<br />APR 1 9 2007
<br />
<br />o
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