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<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 />
<br />:::;::~::::::;TORY FOR VITAL RECORDS. .~~. J. ;"~~
<br />SEP 2 4 2007 ;Vv-' v71TANLEY:S:'~OPER
<br />2 0 0 7 0 9 7 9 2 ASSISTAJtF~ATE PtilGJ~'t8AR
<br />LINCOLN, NEBRASKA HEALT/:t1VlD HUM~~ SERV(CEs
<br />. .~ I I ... .
<br />
<br />~
<br />
<br />
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAf'l SER)/rcES FINANCE,ANDSUR'PORT
<br />CERTIFICA!I:_9F DEATH' .
<br />
<br />.I
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5b, UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />~:IlE)('"; ".>'
<br />.Fema.'ie
<br />
<br />50, UNDER I DAY
<br />HOURS MINS,
<br />
<br />..-:i{J1-1E-
<br />
<br />(First,
<br />Marilyn
<br />
<br />Middle,
<br />Jean
<br />
<br />casl,
<br />Opp
<br />
<br />Suffix)
<br />
<br />'3. DATE. OF DEATH (Mo., Day, Yr.)
<br />September 10. 2007
<br />
<br />Norfolk. Nebraska
<br />
<br />Sa. AGE.cast Birmday
<br />(Yrs,) 60
<br />
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />February 10. 1947
<br />
<br />~.~"~'~_..,,~~,
<br />
<br />"
<br />Bb. FAClcITY.NAME (If not institution, give street end number)
<br />
<br />8a. PCACE OF DEATH
<br />liaSEm!.: 1fllnpatient QlliE8: 0 Nursing Home/nC 0 Hospice Facility
<br />
<br />o ER/Outpatienl 0 Decedent's Home
<br />
<br />7. SOCIAc SECURITY NUMBER
<br />507-68-3683
<br />
<br />St. Francis Medical Center
<br />
<br />OCO\
<br />
<br />o Other (SpecifyL
<br />
<br />Be. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island.
<br />
<br />9a. RESIDENCE.STATE
<br />Nebraska
<br />
<br />68803
<br />19b'COU~all---
<br />
<br />Bd, COUNTY OF DEATH
<br />Hall
<br />
<br />9d, STREET AND NUMBER
<br />105 West 11th St.
<br />
<br />
<br />gUlP CODE
<br />68883
<br />
<br />9g. INSIDE CITY UMITS
<br />
<br />Xl YES 0 NO
<br />
<br />lOa. MARITAc STATUS AT TIME OF DEATH 0 Married 0 Never Married lOb, NAME OF SPOUSE (First, Middle, casl, Suffix) If wife, give maiden name,
<br />
<br />o Married, bul separated 0 Widowed 00 Divorced 0 Unknown
<br />
<br />I I FATHER'S.NAME (Firsl. Middle,
<br />
<br />.~lldwig
<br />
<br />13, EVER IN U,S, ARMED FORCES? Give dates of servica if yes. 14a,INFORMANT.NAME
<br />
<br />No Hap Opp
<br />
<br />caSI,
<br />
<br />SUlfix)
<br />
<br />12. MOTHER'S.NAME (Flrsl, Mlddla,
<br />
<br />Loretta
<br />
<br />Maiden Surname)
<br />Thramer
<br />
<br />15. METHOD OF DISPOSITION
<br />o Burial 0 Donation
<br />lXcremeflon 0 Entombment
<br />o Removal 0 Other (Specify)
<br />
<br />
<br />14b, RECATIONSHIP TO DECEDENT
<br />Ex Husband
<br />
<br />
<br />OTHER cOCATlON
<br />
<br />CITY !TOWN
<br />
<br />I 6c, DATE (Mo., Day, Yr. )
<br />September 17. 200
<br />
<br />STATE
<br />
<br />Westlawn Memorial Park Crematory
<br />
<br />Grand Island. NE
<br />
<br />PART I. Enter the chain of Bvents..disBBSBS, injuries. or compllcations--that directly caused Ihe death, 00 NOT enter terminal events such as cardiac arrest,
<br />raspiratory arrest, or ventricular fibrillation withoul showing Ih. etiology. DO NOT ABBREVIATE. Enter only one cauSe on a Ilna, Add additionelllnes If necessary,
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl..... or condition resuUlng
<br />fndeatl1)
<br />
<br />(a)
<br />
<br />Pu I rn
<br />
<br />Fl brozlS
<br />
<br />I onsel 10 death
<br />I
<br />1'/'5yrJ
<br />.._._,_,.____,." ._1_- "..~..._.
<br />onset 10 deeth
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Sequentially list condition.. If
<br />any, leading to Ihe ceu.ellsted
<br />on IIn...
<br />E_the UNDERLYING CAUSE
<br />(dl...a... or Injury that Initiated
<br />the eventa reaulllng In dealh)
<br />LASf
<br />
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I onset 10 death
<br />
<br />(c)
<br />
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />onsel 10 dealh
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDlTIONS.Condition' contributing to the death but nol resulling in the underlying ceuse given in PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />DYES 0 NO
<br />
<br />20, IF FEMAcE:
<br />
<br />21e, MANNER OF DEATH
<br />)it Nelura' 0 Homicide
<br />
<br />o AccidenlD Pending Investigetlon
<br />
<br />o Suicide 0 Could not be determined
<br />
<br />21b, IFTRANSPORTATION INJURY
<br />o Drlver/Operalor
<br />
<br />o Passenger
<br />
<br />o Pedestrian
<br />
<br />o Olher (Specify)
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />~ Not pregnant within past year
<br />o Pregnant at time of death
<br />o Not pregnant, but pregnant within 42 days ot death
<br />o NOI pregnant, but pregnant 43 days 10 I year before dealh
<br />o Unknown il pregnant within the past year
<br />
<br />DYES Clt NO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPcETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />DYES 0 NO
<br />
<br />
<br />22a, DATE OF INJURY (Mo" Day, Yr,)
<br />
<br />22b, TIME OF INJURY 22c, PcACE OF INJURY.AI home, lerm, slreel, faclory, office building, construclion slle, etc. (Specify)
<br />m
<br />
<br />22d, INJURY AT WORK?
<br />
<br />221, WCATION OF INJURY. STREET & NUMSER, APT. NO.
<br />
<br />CITY/TOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo.. Day, Yr.)
<br />
<br />24e, DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />23d. To the best of my knowledge, death occurred at the time, dats and place
<br />and due 10 Ihe cause(s) Slated. (Signature end Title) "
<br />
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<br />~a:<'>
<br />81;
<br />
<br />m
<br />
<br />24c, PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />240. On the basis 01 examination and/or investigation, in my opinion dealh occurred at
<br />IheOme, dale and place and due to Ihe cause(s) slatad. (Signalure and Title) "
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />o YES NO 0 PROBABcY 0 UNKNOWN 0 YES NO Not Applicable if 26a i, NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY TTORNEY) (Type or Print)
<br />Jennifer L. Brown M.D. 729 North Custer Grand Island. Nebraska 68803
<br />
<br />
<br />28b, DATE mED BY REGISTRAR (Mo" Day, Yr,)
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />SEP 2 0 2007
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