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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT 32211 ry
<br />_____.___~___.__.u_.u".__.~_~.___<<;;~RTIF!fATE OF DEATH ~ .!W
<br />
<br />,. DECEOE~T'S.~AIIE IF"". lI,ddlo toot.
<br />_.~I}' Veryl Tfospe~__________ ____
<br />. CITY AND STATE Oil TERRITORY, 00 FOIIEIGN COUNTRY OF B1IITH
<br />Nance Coun t y ,
<br />--=,~Nebfas~
<br />7. S<XlAl SECUIIlTY NUIl!lER
<br />
<br />Suflll)
<br />
<br />2 SEX
<br />Male
<br />
<br />62
<br />
<br />&1>. U~OER I VEAR
<br />1l0S'-rOAY'S-
<br />
<br />k UNDER 1 Q,l,Y
<br />
<br />HeT
<br />
<br />3. Q,l,TE Of DEATH :110 D." H)
<br />
<br />MaC3, 2006 ~______
<br />
<br />6 DATE O~ BIRTH illo, Oay, Yr.)
<br />
<br />Ju-'L~.~~_._______ _
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<br />S.. AGE.llll81'IM.y
<br />(HI.)
<br />
<br />508. &4-46_~1,
<br />
<br />SIl. FACllITY.HAIlE (II nol ,n"ilUIIOtl, glvo ,t"" .nd number)
<br />
<br />80. P1.ACE Of OUTIl
<br />l:l9~J~!.w.:
<br />
<br />III ,"p"o",
<br />
<br />QlliE!l: 0 >t;nin9 _ TC I:) HooP<:< F .<illy
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<br />::J Oo<odM>f, Homo
<br />
<br />Nebraska Medical Center-University
<br />
<br />Ik CITY OR TOWN OF DUTH (IndU<lt IIp c.".)
<br />
<br />o I.Ul Q OI>eqSptOlfy),,______________
<br />
<br />11<I. COUNTY Of DEAY>i
<br />
<br />Omaha 68198 Q?uglas
<br />h,RESlO(t..:)E.$TATE ~ ']:CITY OR TOWN
<br />
<br />Nebraska ._____--.J Hall Grand Island
<br />Dol. STREET AND HUllBElI . - . ...-.- -- -~~fii:lip.COCi-u -1911 INSIDE CITY 1I111ls
<br />
<br />1404W.Sthstreet ~ L68801 ~ YES 0 NO
<br />10.. IotARllAl STATtlS At TI...E Of DUTK ii3 ....m.d Q N....r II'-r~.. Jll00 HAilE c.F SPOI.JSt (Firll, r.ti<ldle, llll SUlIx) li-;;,i..-;'~.. ...J<3tnn_, - .--.----
<br />
<br />o U..ned. ""',ep.ral.G Q WlGO...d Q 0..0<<0<1 D tJnIrno'ion
<br />Norma Hill
<br />-~~~..._-'..
<br />11. FATHER'S.HAME (Fill" Mlddl., lit" Surtie) 12. MOTHER'S.NAME (Flnl. IIIGdl'. M.Id.n Sum.me)
<br />
<br />Dean Tro~er Lillian Belitz _,,~,,__.._._
<br />---,--;EVEAlNU-S ~AUED;o;cEs? (live dal., ;-.;-;,;;-.~ 1..:-;NroR"';;T~NAr.lE lOb, RElATIONSHIP TO DECEDENT
<br />
<br />(Y... no. or unlL) No _._J Norma Trosper Wife
<br />
<br />15 ;-=O;D~:::~:~II~M~~~_~G~NRi-~~-"--.T6b lAA~# /f~ ._"_",,. _l~_~:A~~ ~~OaY' Yr.)
<br />
<br />Dc...maton Q EntOlllbm&nl 16<1 CEMETERY. CREIlATOAV 0fI Ol'HER lOCATIO'" CITY I TOWN STATE
<br />
<br />Q Rerr<>val 0 other (S"'OI/y)
<br />..._ ________.. ~~~~~_~~~nal Par1\_?~~le2' Grand Isl~~ .~_". ___ Nebraska
<br />17. FUNEAAl >iOME NAr.lEANOllAlllNGADORESS (Slrool. ally 01 Town. 5"''') 1711, lip eo.,.
<br />
<br />
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island. Nebraska
<br />. CAUSE OF OEATH(see
<br />
<br />68801
<br />
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<br />
<br />I ..,.01 "'''''""
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<br />
<br />I
<br />
<br />I On'" .._
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<br />
<br />__________.1,
<br />I ..,.ollo doa"
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<br />__._._1..._ _._.__. _. ___.___.__.
<br />I ",.ollO dO""
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<br />18 PAAT II OTHER SIGNIFICANT CONrnTIONS.Con<lih~-~Otltn""ting 10 ~ ~~;111- but not ""dUng In 111< uocIof1yin9 "\JOe g"en In PART I --.- ----- ~ "J 19 WAS lAHlICAl EXAMINE-R' . -
<br />OR CORONER CONTACTED?
<br />.-____ .._ ._ 0 YES ~ HO ____.
<br />cr: ~. IF FEllAtE: 11.. MANNER OF DUTH 21b.IF TRANSPOfITATlO~ IPjJURY 21c. WAS AN AUTOPSY PERFOR"EO?
<br />i 0 Nolp'~.nl..iU-;np..ty..r birN.tural QHomIado o DriYOf/Op.ralor 0 YES \:riio
<br />:j D Prognonl., ~mo 01 do... 0 AcM.ntO PoOOng m..\~1iotI 0 ""'...-.go< _______~___
<br />if; 0 N.lpregn"~, bul p'0QI"nIYtlttun'2 <lay' 01 d"" 0 Sucido OCooldnolb< d.lo_ 0 Peoe<lnon 21d. WERE AUTOPSY fiNDINGS AVAlLAaE 10
<br />I 0 No! pregnant. ~cl pr'9l1ilnl43 day, I. 1 y..,I><I",. d"" 0 Ot", (SpeCIfy) COIIPlETE CAUSE Q' DUHi?
<br />'l5. 0 UnI:.".,wnllpregnanl",lfon1hep.,lyoa, __._________ 0 YES 0 NO
<br />e
<br />~ - 22a DATE O-F-INJURY-(M~~D'1'-YI;' - "]m1'''E OFIN.JU~';:-PLlCEOf INJURY. A',,";';": f.,,;;:--;;.;;t;;;~lory. .11I<0 buldng. <"'IOll\JFtion 'lie, al.(sp;;"i' --------
<br />
<br />~ 22'U:::T~~7---In-;:iJEsc-~~.:OWIN.JLR~_:~~Elt~~--~----~--- ____~ ---~ ._,,--~"
<br />
<br />
<br />221. LOCATION OF IPjJURY ' STREET & HUUBER, APT. ~. Cffi'1lONN SllTE llP CODE
<br />
<br />APPfIOXIMATE INTERvAL
<br />
<br />IIIMEOlATE CAUSE:
<br />
<br />NoIEOlA TE CAU9E (FNI
<br />dla_or_......
<br />11-'
<br />
<br />la) fe:. p'Ir4..!.11r AY(-a~_.___
<br />OU€ TO. OR AS A CONSEQUENe7OF:
<br />
<br />SeQllOilllaly llot __. .
<br />In! , ~ 10 Ilt <..... Isltd
<br />on hI.
<br />EnIer Ilf lJloIDEHlYJ<<l C.wsE
<br />[cno._ or ~ _ h_
<br />IN! ..~~'. :i.ali;';Ii h ~
<br />IAlr
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<br />: TO.O~OC~;OF~ W
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<br />ks~ cW~~
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<br />A-_l-:~!=L~e.~~~~ ~~_~ c... L ~ LJ. ~~~J,,:_
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<br />DUE TO. OR AS A CONSE QUE NeE OF:
<br />
<br />(e)
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<br />~t
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<br />li~
<br />~ ~15
<br />~I
<br />
<br />230. DAlE OF DEAlt! (\<10.. o.y. VI.)
<br />Ma...L?J..2.~__._
<br />231>.0 Tf SlQNED (Il." Day. Yr.)
<br />5", lol,p
<br />
<br />240. (W.TE SIGHED (II... Day. vq
<br />
<br />2-lb.11ME OF DEATH
<br />
<br />2:k nIlE OF DUrn
<br />1:48 a m
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<br />
<br />23<2. To tI>o bool 01 II?{ knoYtIodQo. iIN" """",,,G at "" amo, a.tt '''''pla'''
<br />.M b Ulllf <llJS<l(a) allllod. ISlpture an4 n.. ) 'f
<br />
<br />tdA- ~ 1--><
<br />
<br />No. PftONOUNCED DUD (101... Cloy, YI.) 2ol4 TIME I'ROWOJNCEDDE.-\O
<br />m
<br />
<br />24.. OIl "" 1>0", Of OIln'ina\on andIor.....agellon, In '" """,on de.... """""" at
<br />.... me. d.lt tnd pia'" tnd _10.... <3010(') stalO<l, (Sop,,"" "'" n..) 'f
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<br />
<br />
<br />~. [liD TOIlACCO USE CONIRI1lUTETO me OCATIfI U.. fiAS OAGAN OR TISSUE OOfjATIO'" BEEN COIISIOE liED?
<br />
<br />----9...!..e.!.....x!lS'__Q~~v Q UNKHOW~ _9 YES r1- NO
<br />2/. NAIIE.llRE ANOADOAESSOF ~RTff1EII (PlfYSIClAN, COIlOllER'S P>iYSfClAHOfI COUt;TY ATTOAIIE'Y1 (1)>>001 P.rG
<br />tAr. ~_CJ.t7(Pfo ...:Veh,~M~ l'\t\W.-i<....t Cf..t~
<br />
<br />i~.,~ --'
<br />
<br />261>. WAS CONSENT GRAHTEO'>
<br />No' AWlc1bI. If zee "NO ~ NO
<br />
<br />{,~ M. I,f(ft -
<br />
<br />
<br />,Ill>. Q,l,TE FILEO BY REGISTRAR (1l0 . Cor. rq
<br />
<br />MAY 1 8 2006
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<br />This'Ciriifies'this d(,cuni~nt to be a true copy of an original record on file with Vital Statistics, Douglas County
<br />Healt;':.~pt., efnjlha, ~braskl:l-fcertified copies must have a raised seal in tbe area to the left. Reproductions
<br />of this gr~bQ.cert(ficate lite n2~gal copies.
<br />""'i1, " , <.,>;)
<br />\\. if I " IE .
<br />Date Issued:" /, QltAy ~"'~8 2006
<br />
<br />."r,
<br />
<br />V'
<br />
<br />'~~. ~
<br />
<br />Registrar:
<br />
<br />AL~'J-
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