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<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTHANJ}.fIiJ!JMN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAJiifECQI!l~;mE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAl!$~S~:.:ifoftT-'~H IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~. .. .E............=-..~.~-....~.'-="..~.i-~.'-.~..~:.'.'.....~"-...:.."t.='.... ..'~..~~..'.....
<br />DATE OF ISSUANCE , _," =0 ~~."'A'~
<br />OCT 1 2 2006 :"~". . FANiS'f-9'.COOffR
<br />ASSistANT S.TATE REGj~'fiAR
<br />HE,rHJWD H!>!MA7!l.SERvlPES
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<br />200707507
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<br />LINCOLN, NEBRASKA
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<br />STA.JEOF NEBRASKA..-. DEPARTMENT OF HEALTH AND HU.MAN SERV. ICES FINANC.EAND'.St)p,pORT n 6 J 0888
<br />___~~ __.' CERTIFICATE OF.DEATI1 _~.Y-- ,
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<br />OECEOENT'S.NAME (First. Middle, Last, Suffix) 2, SEX 3. OATE OF OEATH (Mo" oay, Yr,) \
<br />Maxine Katherine Rupp Female October 3, 2006
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<br />",'; ;" "^'~ ~"'"""~", " '"",,; ;""".; """" l' "",~",,'".. '" ""'" ,,'''k ""'" ,..~ ., .." """" ''', 0", " ,-
<br />(Yrs,) MOS. DAYS HOURS MINS,
<br />Grana Island, Nebraska 92 January 5, 1914
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<br />7, SOCIAL SECURITY NUMaER ~a, PLACE OF OEATH
<br />505- 44- 4 0 5 6 HQSflIAL 0 Inpatient QlliE!l: IX Nursing Home/LTC 0 Hospice Facility
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<br />.. ',",UW",", '" .01 '",,,,,,,.;, ".. ,,,;,,.., "~ - '
<br />U ERlOutpatianl 0 Oacadant'. Homa
<br />Tiffany Square Care Center
<br />o IX)>, U Other (Spacily). .-.
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<br />~:~~TO;~~;~~:lncl~~z~~o;a; __~.~ ~-= l~~U~~Y U~U.~IM"--=--=
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<br />~N~ ! 9c CITY OR TOWN
<br />___~ Grand Island
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<br />-A-: - --- .-__~'--=-J 9;~APT NO_J 9f~~~0~;~=~J99~S~:~ITY~IM~~-
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<br />We, MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married lOb. NAME OF SPOUSE (First, Middla, Lasl, Suffix) if wifa, give maidan name,
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<br />o Divorced 0 Unknown
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<br />11. FATHER'S-NAME (First, Middla, La",
<br />Edward Hann
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<br />1-3: EVERlNU,S -ARMEO FORCES? Givo date. oi"'.fVIce II YeS~O-RMANT'NAME
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<br />~:~'~:~'Ho~~n;~ D::SITION 16a EMaALMER_SIGNATUREJu!-ie ~ille=r:r l6b~ LICENSE Nc;:----
<br />OSurlal OOonallon Not Embalmed
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<br />l6d, CEMETERY, CREMATORY OR OTHER LOCATION
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<br />SUIli')
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<br />12, MOTHER'S-NAME (First.
<br />Catherine
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<br />Mlddla,
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<br />Maidan Surnama)
<br />Peters
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<br />CITY I TOWN
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<br />14b, RELATIONSHIP TO DECEDENT
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<br />Daught~_"___
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<br />16e, DATE (Mo" Oay, Yr,)
<br />Oct 3, 2006
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<br />STATE
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<br />IXCr.matlon 0 Entombmanl
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<br />o Ramoval o Other (Speclly) Central Nebr. Cremation Servic Gibbon
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<br />NE
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<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Streat, City or Town, Slate)
<br />Curran Funeral Chapel 3005 South Locust
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<br />PART I. Ente' Ihe ~ol1..di...ses, injurle., or compllcallon,..thal dlreolty caused the daath, DO NOT enler tarmlnalevants such as cardiao arr.st,
<br />rasplralory arr.sl, 0' ventricular Itbrillalion wllhout showing the etiology, DO NOT ABaREVIATE. Enler only one causa on eline, Add eddilionalllne. II nace.sary.
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<br />DUETO, OR S C
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<br />onset 10 daath
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<br />~~\~~G-.~""~\}~W~(S'" ~'"~R:..~ .~~
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<br />SEQUENCE OF: I on.a 0 dealh
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<br />I onset to death
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<br />IMMEDIATl! CAUSE (FlhlIl
<br />dllIOIlN or condition ,e.ulllng
<br />In dealh)
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<br />IMMEOIATE CAUSE:
<br />(a)~n-
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<br />SeqU.ntlally IIs1 oondlllons, If (b)
<br />.ny, leading lolhe ,,"u..li.ted DUE' TO, OR AS A CONSEQUENCE OF:
<br />on Itne a.
<br />Enter !he UNDERLYING CAUSE
<br />(dl..... or Injury that Initlatad (e)
<br />theeventstesultingln death) . DUE TO,-OR AS A C-ONSEQUENCE OF:
<br />IASf
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<br />~prBgnant wlth;n past year
<br />o pregnant at lime 01 daalh
<br />o Nol pregnant, bUI pragnant wlll1ln 42 day, 01 death
<br />o NOI pregnent, but pregnant 43 days 10 1 yaar before death
<br />o Unknown II pragnant within Iha pa.t year
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<br />22a. DATE OF INJURY (Mo" Day, Yr) _.L OF INJUR:
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<br />22d. INJURY AT WORK? - te DESCRIBE HOW INJlJRY OCCURRED
<br />DYES 0 NO
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<br />221. LOCATION OF INJURY, STREET & NUMBER, APT. riO,
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<br />o AoeidantO Pending Inve.flgalion
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<br />21b, IFTRANSPORTATION INJURY
<br />o DrIver/Operator
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<br />o pas.enger
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<br />o PedestrIan
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<br />o Olher (Speoily)
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<br />_-----L-_
<br />I onset to death
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<br />~19 -WAsMEDICAL EXAMINER-
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<br />OR OORONER CONTACTEO?
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<br />U YES al NO
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<br />21c, WAS AN AUTOPSY PERFORM EO?
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<br />(d)
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<br />18, PART II, OTHER SIGNIFICANT CONOITIONS-Condltlons eontribuling te tha daath but not ra.ulting In ,the underlyln9 cau.. given in PART L
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<br />,,'eNti-
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<br />21a, MANNER OF OEATH
<br />DlNatural 0 Homicide
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<br />DYES
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<br />alNO
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<br />20, IF FEMALE:
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<br />U Suicide OCould nol be datarmlned
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<br />21d, WERE AUTOPSYFINDINGS AVAILAaLETO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES U NO
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<br />22e PLACE OF INJURY.At home, 'arm, street, factory, olllea bUilding, eon.truetlon Slta, ato (Speclly)
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<br />CrTY:rcWN
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<br />STATE
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<br />ZIP COOE
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<br />24a. iJATE SiGI<ED (Mo" D.y, Yr,)
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<br />I 240. TIME OF DEATH
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<br />23a, DATE UF DEAHl (Mo" "ay, Yr.)
<br />_~__- ~.~ 0 b
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<br />l:lffi!zo
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<br />815
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<br />24c, PRONOUNCED DEAO (Mo" Oay, yr.) 24d. TIME PRONOUNOED DEAD
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<br />24e. On the baals of examination and/or investigation, In my opinion dealh occurred at
<br />the tlma, date and place and due to fhe ceuse(s) statad. (Signature and Tllle)"-
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<br />25, DIOTOBACCO USE CONTRlaUTETOTHE OEATH? 26a. HAS ORGAN OR TISSUE DONATION aEEN CONSIOERED? 26b, WAS CONSENT GRANTEO?
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<br />DYES 'm. NO 0 PROBAaLY 0 UNKNOWN 0 YES M NO Not Applleabl. il26a I. NO 0 YES Ja NO
<br />- 27, NAME, TITL~'\>.ND ADDRESS OF CERTIFIERipHYSIOiAN, CORONER'S PHvSiCiANOii COUNTY ATTORNEY) (Type orpii~'
<br />John J. Cannella M.D. 729 N. Custer AV, Grand Island, NE 68803
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<br />26a. REGISTRAR'S SIGNATURE 26b, OATE FILED ay REGISTRAR (Mo., Day, Yr.)
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<br />OCT 1 0 2006
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