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<br />'V
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<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND~HI.lMAN-$l€.RVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL,-'f~CQEIIloOftJ7~}')!ITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlS'fJCS:8ECJ~qN;'W#IGtI.lS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . JtV~.~~f"-;'.u'."~J~Iffj~.~{?~
<br />
<br />DATE OF ISSUANCE JJ'f':fJrAftL~\;f GOOPEFt
<br />JUL 2 1 2006 2 0 0 7 0 6 5 9 9 ASSlsTA.-NT STATE R,EGI{lTPlItR
<br />LINCOLN, NEBRASKA HEAd#ANa H4~,!5ERVI9ES
<br />
<br />-
<br />-... .
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE ANO-SVl"'P9RX'O.. '-'5" ., n. C 0 5
<br />- -- -- ~RTIFICATEOFDEATH u .__.' __._~~
<br />
<br />1. DECEDENT'S.NAME (FirSI, Middla, Last, Sufllx) 2. SEX 3. DATE OF DEATH (Mo" Day, Yr.)
<br />___J:1on_:i~_~ Rose.._~trander Female Se~?~?_
<br />4... CiTY AND.. ST. ATE OR TER....RITORY, OR FOREIGN COU.N TRY OF BIRT.:;- r~.(.~...G.r.:.;Last Birt.hd.a y 5b~~~DE1R ~:~~R H.56U.~~~~..:.: 6. DATE OF 81RTH (Mo., Day, Yr.)
<br />
<br />Ceda.r:~i~_NebrasJ{~~ ... 61_.u. ~ June 20,_ 194~
<br />7 SOCIAL SECURITY NUMBER --r:a PLACE OF DEATH
<br />508- 5 6 - 6 5 7 7 llillif'IT&' X!lnp.lI.nt QJJ:IEB: 0 Nursing Homa/LTC 0 Hospice Facility
<br />----- - -- -----
<br />
<br />.~ :::n:.:::~": :::"": :": ::.~.~.:"m""----i _ ~ :"~"'"' : :::::__
<br />
<br />- 8c CITY OR TOWN OF DEATH (Includa Zip COde) - j8d COUNTY OF DEATH
<br />Kearney 68847 Buffalo
<br />
<br />'-9a;:I~E~C~::E~ ------ J 9b~:~TYl"--- - ] 9C~~:~0~N Island
<br />
<br />9d-STREETANDNUM~'- - --.-~NO 9f ZIP CODE 'I99}NSIDECITYLIMITS
<br />1 008 North Sheridan ----1-___ 68803 _1:& YES 0 NO
<br />
<br />W. .,;,,,,, ''''"'''''"' 0' o~'" CX',,"oo 0 '";"'''''J '" ""' ,..ro"" ''',,,. """. I..,. '""'I "~,,. .;...~" ~~:-- -
<br />
<br />o Marned, bUlsaparaled 0 Widowed U Dlvorcad U Unknown C 1 . f f d 0 d
<br />1 or stran er
<br />l;''-FA.THER'S~~A.M.E (F~;s;:------ ~ --.. .Las~, .. suf;;0..... t22~. MOTH.ER. 'S.NAME(F.ir.SI, .~ Mlddl., - Malden s~rn~
<br />..___Jose~h Nic~olas VKrau~_.~_ Lepna _~iu:.au.s
<br />
<br />13. EVER IN U.S. ARMED FORCES? Glva dates 01 servlca If yes. rI4a.INFORMANT.NAME 14b. RELATIONSHIP TO DECEDENT
<br />(Yas, no. or unk.) No 1 C 1 iff 0 r d 0 s t ran d e r H u s ban d
<br />
<br />t5.~:lr~a~OFDI~~:~::i~:--lt2i;;p~~ ?(/~! .... "t6b.U/dN?~'. 16Cl~T~~:, D~,:r')__2005 ..
<br />
<br />LJ Cramation U Enlombmenl 16d. CEMETERY, CREMATORY OR 01'1 R LOCATION CITY I TOWN STATE
<br />
<br />
<br />''',
<br />
<br />o Ramoval 0 Other (Spacily)
<br />
<br />Main Cemetery
<br />
<br />Belgrade
<br />
<br />Nebraska
<br />
<br />respiratory arrest, or ventricular Ilbrillatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additlonalllne.s if necessary.
<br />
<br />IMMEDIATE CAUSE (Final
<br />dIsease or condition resultIng
<br />In de.lh)
<br />
<br />IMMEDIATE CAUSE . I on sat to daath
<br />
<br />(a) =u~~ ((?~i"_e--f~ ---.dJ~- tD trn- ),4~ i
<br />
<br />DUETO,ORASA CONSEQU"NCE OF' c;-'f'~ ~-"~~ ' -I . : onsallodealh
<br />
<br />I
<br />I
<br />I onsel to dealh
<br />I
<br />I
<br />
<br />...~-.__._.
<br />
<br />SequenllaUy Usl condlllons, If (b)
<br />.ny, leading 10Ihacaus.UsI.d o-ui TO, OR AS A"60NSEOUEN6E-~
<br />on line a.
<br />Entar Ih. UNDERLYING CAUSE
<br />(dl..... or Injury Ih.llnlll.t.d (cl
<br />th. avanls ,.sultlng In daath)
<br />~
<br />
<br />- - ._~~._'--~"--"'-
<br />DUE TO, OR AS A CONS"QUENCE OF:
<br />
<br />onset to death
<br />
<br />~ I
<br />
<br />18 PART II OTHER SIGNIFICANT CONDITIONS.Condlllons conlrlbullng 10 Iha dealh but nOI r.sulllng In tha undarlYI~~ ~.usa given In PA-~ ~9 WAS MEDICAL EXAM~
<br />
<br />OR CORONER CONTACTED?
<br />
<br />o YES III NO
<br />- --"~ ..--- --
<br />20. IF FEMALE: 21a. MANNER OF DEATH 21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />II Nol pragnantwithin past year II Nalur.1 U Homicid. 0 Driv.r/Oparalor 0 YES Ii1l NO
<br />
<br />o Pr.gnant sl lime of death 0 AccidentD Pending Invasllgallon 0 passangar .,,_. .__ .____.,
<br />
<br />o Not pragnant, but pragnant within 42 days of daalh 0 Sulclda 0 Could 001 bo dalarmlnad 0 Padastrlan 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Not pragnant, bUI pr.gnant 43 days 10 1 yaar baforo d.alll 0 Olher (Spacify) COMPLETE CAUSE OF DEATH?
<br />o Unknown If pragnanl wlthrn Iha p.SI year U YES U NO
<br />
<br />-2-2aDA~OF INJURY (Mo" -Day. Yr.) ~ I: TIM" OF I~JUR~122C PL_ACE OF INJURY.At homa, farm, straal, factory, Of~lco bUII~lng, con~t~u~'I~n Site, ~~c (~p_a~'IY) _ _. __
<br />
<br />22d INJURYATWORK;j20 D"SCRISEHOWINJUAYOCCURRED ,- --- -- .--- --- -
<br />o YES''1NO
<br />----- -- ~---- --------
<br />22f. LOCATION OF INJURY. STREET & NUMRER, APT. NO. CITYIfOWN STATE liP CODE
<br />
<br />~-""""'"""----,~~-~-~
<br />
<br />.--.---.--------r
<br />
<br />2005 ~~i
<br />23c. TIME O-;;-DEA-r;;-- . ~ !(! ~
<br />/;00 pm -a.il:<=:;
<br />g~1:1j
<br />uwz
<br />1l1ji5
<br />~~~
<br />00
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />2419, On the basis of examination and/or Invesllgation, in my opinion death occurred at
<br />Ihollma, data ond place and dua to Iho cause(s) Slaled. (Slgnalura and Tilla) T
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />DYES Il NO 0 PROBABLY U UNKNOWN a YES :C~ NO
<br />27. NAME: TITLE ANOADDRESS oi'cmTIFIER (PHYSICIAN, COFI()Nm'S PHYSiCiAN OR COUNTY ATTORNEY) (Typa Or Prinl) ..
<br />
<br />26b. WAS CONS"NT GRANTED?
<br />NOI.Applicablalf_~6.~.ls NO il YE~...._
<br />
<br />28b. DATE FILED BY R"GISTRAR (Mo., Day, Yr.)
<br />SEP 2 6 2005
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