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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 BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISa_ ,69C WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - ,/�_
<br />DATE OF ISSUANCE LLNr
<br />JUL 7 zoo 2 0 0 7 0 7 4 0 3 -= LAY s.pER
<br />ASSIS7ANT_STATE REGISTRAR
<br />LINCOLN, NEBRASKA WEALTH AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICEST -WANCE AN p�I O
<br />CERTIFICATE OF DEATH - U 2 7 8 6 3
<br />1. DECEDENT'S•NAME (Fire!,
<br />Beverly
<br />Middle,
<br />A.
<br />Last, Suffix)
<br />Sullivan
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF 131RTH 15a. AGE -Last Birthday 8b. UNDER 1 YEAR
<br />(Yrs.) MO$, I DAYS
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505 -44 -3952
<br />81b. FACILITY•NAME (If not institution, give street and number)
<br />1224 W. Koenig ST
<br />69
<br />88, PLACE OF DEATH
<br />HOISELIA.L 0Inpatient
<br />2. SEX
<br />Female
<br />5c, UNDER 1 DAY
<br />HOURS I MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr,)
<br />July 21, 2007
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />January 19, 1938
<br />ME & ❑ Nursing Home/LTC ❑ Hospice Facility
<br />❑ ER/Outpatlent 2[ Decedent's Home
<br />❑ OOi ❑ Other (So")___
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />Grand Island, 68801 Hall
<br />ga.RESIDENCE -STATE 9b. COUNTY 9c. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />9d.STREET AND NUM13ER 98. APT. NO I 9f. ZIP CODE 99. INSIDE CITY LIMITS
<br />1224 W. Koenig ST 6801 I $ YES ❑ NO
<br />108. MARITAL STATUS AT TIME OF DEATH y[Married ❑ Never Married lob NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />J Married, but separated ❑ Widowed ❑Divorced ❑unknown Maurice J. Sullivan
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle. A9aiden Surname)
<br />_August Claus, Rohweder Florence Wilmarth
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If yes. 14a.INFORMANTNAME 14b. RELATIONSHIP TO DECEDENT
<br />(Yes, no, orunk.) NO Maurice J. Sullivan Husband
<br />15. METHOD OF DISPOSITION 16e:EM 9R- SIGNATURE y t6b. LICENSE NO. 16c. DATE (Mo., Day, Yr,)
<br />IgBWIaI CJ Donation ` ,/ ...,.__1092 Jul 25, 2007
<br />❑Cremation ❑Entombment 100. CEMETERY, CREMATOR`y OR OTHER LOCATION CITY /TOWN STATE
<br />13 Removal ❑ Other (Specify) Grand Island City Cemetery Grand Island NE
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code
<br />Curran Funeral Chapel 3005 South Locust Street , Grand Island, NE 68801
<br />18. PART I. Enter the chain of evEtUg.- diseases, injuries, or complications- -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular
<br />fibrillation without showing the etiology DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />I
<br />IMMEDIATE CAUSE: -
<br />I onset to death
<br />IMMEDIATE CAUSE (Final
<br />(a) ��1..5 w �47\�� �Z (� ( C r
<br />r� �•-
<br />-
<br />a
<br />dhr0aseorconcif9onresulUng
<br />DUE TO, OR AS A CONSEQUENCE OF- _
<br />on to death
<br />In death)
<br />I
<br />Sequentially list conditions, if
<br />(b)
<br />I
<br />any, leading to the cause listed
<br />online a.
<br />DUE T0, DR AS A CONSEQUENCE OF! �W
<br />I onset to death
<br />Enterthe UNDERLYING CAUSE
<br />(disease or injury that Initiated
<br />(c)
<br />the events resulting in death)
<br />" - -- -- -- - - - -.-
<br />. DUE T0, OR AS A CONSEQUENCE OF:
<br />.__
<br />onset to death
<br />LAST
<br />I
<br />18 PART II OTHER SK'NIFICANT
<br />(d)
<br />CONDITIONS C d'f
<br />I
<br />• - on i ions contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES DE NO
<br />20, IF FEMALE! 21a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />,f`AWl pregnant within past year Natural ❑ Homicide ❑ Driver /Operator
<br />Cl Passenger ❑ YES NO
<br />• Pregnant at time of death ©Accident❑ Pending Investigation gar
<br />• Not pregnant, but pregnant within 42 days of death ❑ Pedestilan 21d WERE AUTOPSY FINDINGS AVAILABLETO
<br />❑Suicide ❑Could ndt be determined
<br />0 Not pregnant, but pregnant 43 days to 1 year before death V Other (Specify) COMPLETE CAUSE OF DEATH?
<br />❑ Unknown if pregnant within the past year ❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, YcT 22b. TIME OF INJl1Fl � 22c. PLACE` _ T r. �e - �
<br />- -- OF INJURY -At home, farm, street, factory, office dullding, construction site, etc, (Specify)
<br />22d. INJURY AT WORK? 122a. DESCRIBE HOW INJURYOCCURRED
<br />❑ YES ❑ NO
<br />22f, LOCATION OF INJURY - STREET A NUMBER, APT NO, CITY/iOWN
<br />STATE ZIP CODE
<br />23a. LATE OF DEATH (Mo., Day, Ya) z 24a. DATE SIGNED tMo„ nay, Yr,) 24b. TIME OF DEATH
<br />_ __ m
<br />} 23b. DATE SIGNED (Mo., Day, Yr,) 23c. TIME OF DEAT 24C. PRONOUNCED DEAD (Mo., Day, Yr,) 24d. TIME PRONOUNCED DEAD
<br />�aao m E €a= m
<br />23d. To the best of my knowledge, death occurred at the time, date and place 0 240. On the basis of examination and/or investigation, in my opinion death occurred at
<br />and a causes) stated. (Signature and Tie ♦ the time, date and place and due to the cause(s) stated. (Signature and Title ) ♦
<br />F
<br />25, DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HASORGANORTISSUE DONATION BEEN CONSIDERED? 26b.WAS CONSENT GRANTED?
<br />❑ YES NO ❑ PROBABLY _0 UNKNOWN _❑ YES 1N NO Not Applicable if 26a is NO ❑ YES X NO
<br />2Z NAME, TITLE AND ADDRESS OF CERTIFIER ( PHYSICIAN, CORONER'S PHYSICIAN OR COUNTYATTORNEY) (TypecrPrint)
<br />John J. Cannella M.D. 729 N. Custer AV, Grand Island, NE 68803
<br />1, r 28a. REGISTRAR'S SIGNATURE A1. &M, - - 28b.DATJULY/Lr REGISTRAR
<br />�oU/ Day, Yc)
<br />
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