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<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 RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. J.~" f1~- .
<br />
<br />DATE OF ISSUANCEHh11LM fl.; 't"'lf"
<br />SEP 1 8 Z007 ;VVW""7JTANi.sWS.:.o<<>PEfI
<br />2 0 0 7 0 8 7 t 3 ASSISTANT.67:1tr.e-REGl$1'RAFI
<br />LINCOLN, NEBRASKA HEALTI;IAtl1UHUMA/l.StR4Ar;i'S
<br />- . lI'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINAJIICq"AN1!I6V?P. 1> . '.- ',5', 3
<br />CERTIFICATE OF DEATH 'i~ ~ ,-,?": ,I.,
<br />
<br />)
<br />
<br />1. DECEDENT'S-NAME (First. Middle.
<br />Douglas Wile Brockman
<br />4. CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />
<br />last,
<br />
<br />
<br />Suffix)
<br />
<br />2. S EX'~ ::.,. ~~
<br />
<br />Sa. AGE-last Birthday
<br />
<br />(Yrs.)
<br />
<br />72
<br />
<br />October 11, 1934
<br />
<br />Burwell, Nebraska
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />507-40-9971
<br />8b. FACILITY-NAME (If not Institution. glv~ street and number)
<br />
<br />8a. PLACE OF DEATH
<br />~:
<br />
<br />iii Inpatient
<br />
<br />O'lHEA: 0 NUlling Homell TC 0 Hospice Fadllty
<br />
<br />o ER/Oulpatlent
<br />
<br />o Decedenfs Home
<br />
<br />w
<br />a:
<br />S
<br />~
<br />a:
<br />W
<br />~
<br />i
<br />
<br />I
<br />
<br />li
<br />g,
<br />g
<br />u
<br />i!
<br />~
<br />
<br />000'1
<br />
<br />o Olller(Spedly)
<br />Bd. COUNTY OF DEATH
<br />
<br />Saint Francis Medical Center
<br />8c. CITY OR TOWN OF DEATH (InclUde Zip Code)
<br />
<br />Grand Island 68803
<br />Ba. RESIDENCE.STATE
<br />
<br />Qb.COUNTY
<br />
<br />
<br />gr. ZIP CODE
<br />
<br />99. INSIDE CITY LIMITS
<br />GiI YES 0 NO
<br />
<br />Hall
<br />
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />
<br />317N.Ara ahoe
<br />lOa. MARITAL STATUS AT TIME OF DEATH iii Married 0 Never Ma",ad
<br />
<br />68803
<br />lOb. NAME OF SPOUSE (First. Middle, Last, SUfllX) If wife, give maiden name.
<br />
<br />o Marned, but separated 0 Widowed 0 Olvorced 0 Unknown
<br />
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />
<br />(First,
<br />
<br />11. FATHER'S-NAME (First, Middle, Last,
<br />Vernon Brockman
<br />t3. EVr IN Ul' ARMED FORP~S?I \aJVj dales 01 service ilyes.
<br />10 10 "i7-10/~ ~':I
<br />(Yes, n ,or un .) '""fes -
<br />15. METHOD OF DISPOSITION 16a. ALMER.SIG
<br />~ Burial 0 Donallon V
<br />o Cremation 0 Entombment
<br />o Removal 0 other (SpeCify)
<br />
<br />16b. LICENSE NO.
<br />/07/
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Wife
<br />16c. DATE (Mo., Day, Yr. )
<br />
<br />September 15, 2007
<br />STATE
<br />
<br />CITY / TOWN
<br />
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />
<br />Grand Island City Cemetery
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street. City or Town, slete)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />Grand Island
<br />
<br />CAUSE 0
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />Instructions and sxsmp es
<br />
<br />tB. PART I. Enter the chain 01 events.,dlseases.lnjurles, or compllcaUons..that dlreclly caused the death. DO NOT enter terminal events SUCh as cardiac arrest
<br />respiratory arresl. or ventricUlar IIbrlllaUon without showing the eUology. DO NOT ABBREVIATE. Enter only one caus. on a line. Add addlUonalllnes If necessary.
<br />IMMEDIATE CAUSE:
<br />
<br />onset to death
<br />
<br />IMMEDIATE CAUSE (Fhal
<br />dll_ II" condRlon retURlng
<br />h deall1)
<br />
<br />(a)
<br />
<br />> U./)p(N
<br />
<br />I"L HilS
<br />
<br />t A--~
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset 10 death
<br />
<br />BaquanUa11y Ust oondlllol1l, U
<br />any, Ie8dIng to lI1a cBUM Osled
<br />on llno a.
<br />Enler 11. UNDERLYING CAUSE
<br />(dl..... or In/UIJ 1hI1., II/alsd
<br />1h.1VII11o relUllng n d.el1)
<br />lJSr
<br />
<br />(b) I S eM- tMI\ "c....
<br />DUE TO, OR AS A CONSEQUE NCE OF:
<br />
<br />t- />1V) (14 /f' 'f 0 I' M1f 'f
<br />
<br />!yil
<br />
<br />onsel to death
<br />
<br />(c)
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />
<br />onsel to death
<br />
<br />(d)
<br />
<br />lB. PART II. OTHER SIGNIFICANT CONDITIONS.Condlllons contrlbullng to the death bul not resulting In the underlying caUSe given In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTEO?
<br />
<br />o YES NO
<br />
<br />() (/\ th. (t )
<br />
<br />t-E-t r
<br />
<br />a:
<br />w
<br />ii:
<br />~
<br />w
<br />u
<br />j
<br />1:
<br />0;
<br />g,
<br />!
<br />
<br />21b.IFTRANSPORTATlON INJURY
<br />o Driver/Operator
<br />
<br />o Passenger
<br />
<br />o Pedestrian
<br />
<br />o Olher (SpeCify)
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />21a. MANNER OF DEATH
<br />~tural 0 HomiCide
<br />
<br />o AccidentO Pending InvesUgation
<br />
<br />o Suicide 0 could not be determined
<br />
<br />20. IF FEMALE:
<br />
<br />
<br />o Not pregnant within past year
<br />
<br />a Pregnantet time 01 death
<br />
<br />o Not pregnant, but pregnant Within 42 days 01 death
<br />
<br />o Not pregnant, but pregnanl43 days to 1 yearbelore dealh
<br />
<br />a Unknown If pregnant wllhln the pas I year
<br />
<br />o YES ~O
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES 0 NO
<br />
<br />22a. DATE OF INJURY (Mo.. Day, Yr.)
<br />
<br />,. , .
<br />22b. TIME OF INJURY 22e. PLACE OF INJURY.At home, farm, slr..l, laelory, olnelbulldlng, conatrucUon Sltl, ItC. (SpeCify)
<br />m
<br />
<br />..
<br />III
<br />{!. 22d.INJURYATWORK?
<br />
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />Ll YES 0 NO
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYrl'wm
<br />
<br />ZIP CODE
<br />
<br />Sl1ITE
<br />
<br />
<br />23a. DATE OF DEATH (Mo.. Day, Yr.)
<br />_ Il--01
<br />
<br />24a. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />241>. TIME OF DEATH
<br />
<br />~ti
<br />~-z
<br />""2a:
<br />i!l!2
<br />l~!i~
<br />e.....z
<br />si5!ZO
<br />"z:J
<br />'<>08
<br />,2~~
<br />uo
<br />
<br />24e. On lI1e basls 01 examlnaUon and/or Inveatigallon, In "'f opinion death occurr.d al
<br />the bme, date and place and due to the cause(s) stated. (Signature and Tille) ...
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo.. Day. Yr.) 24<1. TIME PRONOUNCED DEAD
<br />m
<br />
<br />and due 10 the cau
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO 0 YES
<br />
<br />o
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />o YES 0 0 PROBABLY 0 UNKNOWN 0 YES NO
<br />27. NAME, TITLE A D ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUN ATTORNEY) (TYPe or Pnnt)
<br />David Colan M.D. 729 N. Custer Av Grand Island NE
<br />
<br />68803
<br />
<br />2Ba. REGISTRAR'S SIGNATURE
<br />
<br />
<br />2Bb. DATE FILED ~~ISYA4 (M~~d7 Yr.)
<br />
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