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<br />~
<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 13EJXJREU'JN:Kl'::E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI~~~CTI(!/)l,=~wtlJfH IS
<br />
<br />:~:~;:~::~TORY FOR WTAL RECORDS. ~~~
<br />
<br />MAR 1 7 2005 2 0 0 7 0 6 5 4 ,. A$$I$h4NTs.iilrFillfcl~ST-RAR
<br />LINCOLN, NEBRASKA, HEA.~tHAfl!.O~'!A41f" S/!RVU;ES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANtEA~.)~U.' ~.PORT '0" 1:.,-''''0 2 9 5 3
<br />. ...__ ~E:.R..!IE!~ATE OF DEATH-'::.,:-....o:"" L -o_~e-
<br />
<br />lJ
<br />,
<br />
<br />1. DECEDENT'S.NAME
<br />
<br />(First,
<br />Charles
<br />
<br />Middle,
<br />otis
<br />
<br />Last,
<br />Brown
<br />
<br />Sulllx)
<br />
<br />2, SEX
<br />Male
<br />
<br />-. '~of-DEATH (Mo" Day, Yr.)
<br />March 8, 2005
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Gibbon, Nebraska
<br />
<br />Sa. AGE.Last Blrlhday 5b. UNDER 1 YEAR
<br />(Y,",) 81 M~~]-DAYS
<br />
<br />
<br />8a, PLACE OF DEATH
<br />
<br />50, UNDER 1 DAY 6, DATE OF BIRTH (Mo" Day, Yr,)
<br />HOURS MINS. Septmber 30, 1923
<br />
<br />."
<br />"~
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />506-22-6296
<br />
<br />I::lQ.SELTAL:
<br />
<br />XI Inpatient
<br />
<br />~: 0 Nursing Home/LTC 0 Hosplca Facllliy
<br />
<br />8b, FACILlTY.NAME (II not Ins1ltu1l0n, giva street and number)
<br />st. Francis Medical Center
<br />
<br />U ER/OulpaUenl
<br />
<br />o Decedent's Home
<br />
<br />o Divorced 0 Unknown
<br />
<br />o 0Cl<\ W Other (Specify). .
<br />- . ..__-~~~-~ 8d, COUNTY OF DEATH Hall
<br />
<br />
<br />I gc. CITY OR TOWN
<br />
<br />
<br />J:~i'~~j~~1;-;~
<br />
<br />lOb. NAME OF SPOUSE (First, Mi~dle, Last, Sutllx) If wife, give mai~en name,
<br />Germaine Labenz
<br />
<br />9g, INSIDE CITY LIMITS
<br />["~ YES !i NO
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />
<br />9a;:~~~'~~~_19b.~;;~_~.
<br />
<br />9d. STREET AND NUMBER
<br />3507 Farmstead Road
<br />lOa. MARITAlS'fATUS AT TIME OF DEATH~ M~-;;;;d- U Never Married
<br />
<br />Middle,
<br />
<br />Lasl,
<br />Brown
<br />
<br />Suffix)
<br />
<br />12, MOTHER'S.NAME (Firsl,
<br />Edith
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />
<br />Johnson
<br />
<br />13, EVER IN U,S, ARMED FORCES? Give deles 01 service If yes, 14a,INFORMANT.NAME
<br />No Germaine Brown
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />W Burial
<br />
<br />o Donation
<br />
<br />16a. EMBALMER.SIGNATURE
<br />Not Embalmed
<br />
<br />----J.m--.
<br />I 6b. LiCENS~ NO,
<br />
<br />... -- ''''''''''''" .,'..""---,,, .,.----
<br />
<br />160, DATE (Mo" Day, Yr, )
<br />March 9, 2005
<br />
<br />STATE
<br />Nebraska
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />Q[Cremation 0 Entombment
<br />
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN
<br />Central Nebraska Cremation Service Gibbon
<br />
<br />o Ramoval 0 Othar (Specify)
<br />
<br />I'
<br />
<br />
<br />17b, Zip Code
<br />68801
<br />
<br />17a. FUNERAL HOME NAME AND MAiliNG ADDRESS (Streel, City or Town, Stale)
<br />Funeral Horne, 2929 S. Locust
<br />
<br />t
<br />
<br />PART L Enter Ihe c,b~l('I pI ~vflllt5--rliseasE's, injuries. or f;ompllcationsnthat directly r.allsflrl the death. 00 NOT en\e-r !er~he.!.e'lenls s:Jch as cardiac arrest,
<br />respiratory arr.sl, 01 ventricular fibrillation without showing Iha aUology. DO NOT ABBREVIAT~. ~nlar only one caus. on a line, Add addlllonalllnes If necessary,
<br />
<br />Sequentially 11.1 condition., If
<br />any, leading to the cause listed
<br />on line a.
<br />Enter the UNDERlYING CAUSE
<br />(dl..... or fnJury that Initiated
<br />the eVents. resulting In death)
<br />~
<br />
<br />(b)
<br />
<br />Cqgg NAK'y
<br />
<br />A!<T f::j~ y
<br />
<br />D (S~Sl;;'
<br />
<br />I
<br />I
<br />
<br />I onselto death
<br />I
<br />I
<br />I
<br />I on.elto death
<br />I
<br />I
<br />
<br />. ..~----'-._._--
<br />I onsello dealh
<br />
<br />H-o()((
<br />
<br />IMMEDlAT~ CAUSE:
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl..e.. or oondltlon r..ulllng
<br />In death)
<br />
<br />(a)
<br />
<br />cAf<D10G6N \C'.)
<br />
<br />S lfOc-k:
<br />
<br />DUE TO, OR AS A CONSEQU~NCE OF:
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />
<br />(c)
<br />
<br />DU~ TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to dealh
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDlTIONS.Cnndllions oontrlbullng to Ihe death but not resulting In the underlying cause given in PART I.
<br />
<br />S 6lJ ~e; N lf~ P...&UP-O I LA{ L 0 IN
<br />C () N Lc e~rcvG -- k:b _ ~T :-t
<br />
<br />20, IF FEMALE:
<br />
<br />
<br />19, WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACT~D'
<br />
<br />o YES XI NO
<br />
<br />o Not pregnant within past year
<br />o Pregnant at lime 01 death
<br />o Not pregnanl, but pragnanl within 42 days 01 dealh
<br />o NOI pregna"t, bUI pregnant 43 days 10 1 year before dealh
<br />U Unknown if pregnant wilhin the past year
<br />
<br />21a, MANNER OF DEATH
<br />~a.lural 0 Homicide
<br />
<br />o AccldenlO Pending Investigetion
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />o Drl'or/Operalor
<br />
<br />o Passenger
<br />
<br />o Pedestrian
<br />
<br />21 c, WAS AN AUTOPSY PERFORMED?
<br />
<br />DYES
<br />
<br />~ NO
<br />
<br />o Suicide 0 Could nol bo delarmined
<br />
<br />o Olhar (Specify)
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABL~ TO
<br />COMPLET~ CAUSE OF DEATH?
<br />
<br />DYES
<br />
<br />UNO
<br />
<br />22a. DATE OF INJURY (Mn., Day, Yr.)
<br />
<br />
<br />m
<br />
<br />22b, TIME OF INJURY 22c, PLACE OF INJURY.AI home, farm, slroel, laclory, ofllce building, construclion slle, etc, (Specify)
<br />
<br />221, LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STAT~
<br />
<br />ZIP CODE
<br />
<br />
<br />fi?"1
<br />
<br />23c, TIME OF DEATH
<br />8 :43 p~
<br />
<br />z>
<br />~~~
<br />'\lUll!:
<br />H~
<br />c.c.. ~ ~
<br />Etn;::z
<br />8ffizo
<br />llz::>
<br />,2:f8
<br />o ~
<br />U 0
<br />
<br />24c, PRONOUNCED DEAD (Mo" Dey, Yr,) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis ot examination and/or invBstigation, in my opinion death occurred at
<br />the time, date and place and due 10 fhe causers) slatad. (Signature and Tille) T
<br />
<br />25, DID T08ACCO USE CONTRIBUTE TOTHE DEATH? 2Sa. HAS ORGAN OR TISSUE DONATION BEEN CO~SIDERED? 26b, WAS CONSENT GRANTED?
<br />
<br />DYES W NO 0 PROBA~LY )( UNKNOWN 0 YES NO NOI Applicable If 26a Is NO 0 YES 0 NO
<br />?7-';"'". TITLF ANIl'nn~F,~~ OF C~RTIFIEA (~HYSICIAN, cORONER:S PHYSiCiAN OR COUNTY ATTORNEY\ ITvoe or Print)
<br />nirnanshu Agarwal, M.D. 3515 RichItPnd Circle Grand Island, NE 68803
<br />
<br />28a, REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mn., Day, Yr.)
<br />
<br />MAR 1 4 2005
<br />
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