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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 NEEJRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />
<br />:::;::~~:::::~TORY FOR VITAL RECORDS. .~~M. J.:~ ~.. ~.
<br />
<br />2 4 JV"-'''fJTAIY~YS. COOPER
<br />AUG Z007 20070...9573 ASSISTAIiTS"rATE'RSQlSTRAR
<br />LINCOLN, NEBRASKA HEA'-:'fH; AND HU't!ttfSfB,.VICES
<br />
<br />._: ,~v' '-r~; ;, " ,
<br />
<br />S. TATE OF NEBR. A.S KA - DER..A. .RTMENT a..F.. HEALTH AND HUMAN SERVICE1!li:INANC.E AND SUPPA~ 2 8 9 8 7
<br />.--- ._.~.__ .. CERTI_FICATE OF DEATH ... ..' , U:f
<br />Middle. Last, Suffix) 2.,.S~'., ... ", : -i DATE OF DEATH (Mo" Day, Yr.)
<br />. ___Joanne Gertrude HImes -p'm 'f...... . Au ust 9 _.2007
<br />
<br />~
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />
<br />eptember 8,1942
<br />
<br />Sa. AGE.Last Birthday 5b. UNDER 1 YEAR
<br />(Yrs.) 64 -Mor'
<br />
<br />
<br />aa. PLACE OF DEATH
<br />
<br />6. DATE OF BiRTH (Mo" Dey, Yr.)
<br />
<br />Wisconsin
<br />
<br />J:iQS.E.lIAh:
<br />
<br />o Inpatient
<br />
<br />QlliEB: 0 Nursing Home/LTC 0 Hospice Facility
<br />
<br />o ER/Outpatlent
<br />
<br />o Decedent's Home
<br />
<br />DlXl'.
<br />
<br />-GOther(SpeCI~killed car
<br />
<br />ad. COUNTY OF DEATH
<br />Hall
<br />
<br />ge. RESIDENCE-STATE
<br />Nebraska
<br />
<br />68803
<br />"=rO~;ll
<br />
<br />9c. CITY OR TOWN
<br />Grand Island
<br />
<br />~=~T.NO 9~Z~~O~~
<br />
<br />lOb. NAME OF SPOUSE (First, Middle, Last, Sumx) Itwite, 91ve maiden name.
<br />
<br />~S. IDE CiTY LIMiTS
<br />XI YES 0 NO
<br />
<br />9d. STREET AND NUMBER
<br />1325 N. Hancock Ave.
<br />
<br />'-oa. MARITAL STATUS AT TIMEOF DEATH IXMerried 0 Never M.rrled
<br />
<br />o Divorced 0 Unknown
<br />
<br />Melvin Holmes
<br />
<br />11. FATHER'S.NAME (First, Middle,
<br />Clemens
<br />
<br />Last, Suffix)
<br />Zenk
<br />
<br />12. MOTHER'S-NAME (First,
<br />Mollie
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />
<br />,_~uppel
<br />14b. RELATIONSHIP TO DECEDENT
<br />husband
<br />16c. DATE (Mo" Day, Yr.)
<br />August 15,.. 2007
<br />STATE
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes.
<br />No
<br />
<br />14a.INFORMANT'NAME
<br />Melvin Holmes
<br />
<br />J ~";;NO.
<br />
<br />ON CiTY / TOWN
<br />
<br />o Donation
<br />
<br />
<br />o Entombmant
<br />
<br />o Other (Specify) Grand Island City Cemetery
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />
<br />17a. FUNERAL HOME NAME AND MAiLING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home,
<br />
<br />PART I. Enter the chain of Bvents~-djseasas, injuries, Or complications--that directly caused the death. DO NOT enter terminal avents such as cardiac arrest.
<br />respiratory arrest, Or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE, Enter only one cause on a linB. Add additional lines jf necessary.
<br />
<br />INlMEDIATE CAUSE (Final
<br />dl..... er =dltlon resulting
<br />In death)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />N\~\ ~:f-..,- ~ .('(-~, ~
<br />
<br />tf\
<br />
<br />I onsel to death
<br />I
<br />I -- ,\ ,\f\.\
<br />._--~. --.
<br />onset 10 death
<br />
<br />(a)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Sequonll.lly 1101 condltlen., II (b)
<br />.ny, leading 10 tho couoell.tod DU'E TO, OR AS A CONSEQUEN6~'-~--~
<br />On line a.
<br />Enterlho UNDERLYING CAUSE
<br />(di....e or InJurylhotlnltlated (e)
<br />thoovenl. ...ulllng In death)
<br />I.A';T
<br />
<br />onaet to death
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS.Conditlons contribuling to the death but not resulting In Ihe underlying CauSe given in PART I.
<br />\J,h~ ~ <;. Q n N':lt. (11N\ " f'(\ ~"'\ !:.
<br />~"~-\"t. f~ tv..-/ ('Vl\t-~ ~ t1\1'~" \-t SA \. '::. \(' ....tfU) ~~""',, ,
<br />
<br />20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURV
<br />}iNatural CI HomicidB 0 Driver/OperalOr
<br />o Passenger
<br />o Pedestrian
<br />
<br />19 WAS MEDICAL EXAMiNER
<br />OR CORONER CONTACTED?
<br />:.\ 0 YES :(NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />Q AccidsntCl Pending Investlgation
<br />
<br />o YES ~O
<br />
<br />o NOI pragnant, but pregn.nt within 42 days of death
<br />o Not pregnant, but pregnant 43 days to 1 year belore death
<br />Q Unknown if pregnant within the past year
<br />
<br />o Suicide 0 Could not be delermined
<br />
<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />o Other (Specify)
<br />
<br />no.DATE OF INJURY (Mo.. Day, Yr.)
<br />tJ\1\
<br />
<br />22d.INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />22b. TiME OF INJURY
<br />
<br />22c. PLACE OF lNJURY.Al home. farm, street, factory, office building, construction 5ite, etc. (Specify)
<br />
<br />m
<br />
<br />CfTYlTOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo" Day, Yr.)
<br />,?007
<br />
<br />24a. DATE SIGNED (Mo. Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />"'~~
<br />:g~a:
<br />~?i~
<br />o..CL4:~
<br />lj!tl>z
<br />llffi!iiO
<br />1IZ::>
<br />~~~
<br /><>0
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TiME PRONOUNCED DEAD
<br />m
<br />
<br />24e, On the basIs of examination and/or investigation, in my opinion death occurred at
<br />the time, date and plaoe and due to the oause(s) stated. (Signature and Title) T
<br />
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 2aa is NO 0 YES }(NO
<br />
<br />Nebraska 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo" Dey. Yr.)
<br />
<br />AUG 2 2 2007
<br />
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