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<br />STATE OF.NEBRASKA
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<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL.TH AND I-/IJMAN SERVlCE$
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THEORIGINALR6fRjRiiUfff:JLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM VITAL STATISreSSEC-TioN jVHiCH IS
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<br />:~:~::::::;TORY FOR YITAL RECORDS '/BiJ:l: ~~ I
<br />FES 0 6 200? ~""'flUN~Y $.j;Qo'!!tfl
<br />A~/ST~NT STATE REGLSTRM
<br />HEif~rH ANP H,UM.Jl'-f?1!RVi/!tS
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<br />200709910
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<br />LINCOLN, NEBRASKA
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<br />DECEDENT'S-NAME (First, Middle, l.st, Suffix) 2, SEX 3, DATE OF DEATH (Mo" D.y, Yr,)
<br />___ __ Le~mard ~y_Dawso~ _ _ __ Male_ January~~_2007
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<br />4 CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRT~5~~ AGE-l.SI Blrthd-;-~5~ UNDER 1 YEAR
<br />Woods en county, KanSaS_~(Yr.) 90~~YS
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<br />7 SOCIAL SECURITY NUMBER 38. PlACE OF DEATH
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<br />51 3 - 0 3 - 69 8 0 !iQSl'JIAJ.' ~ Inpatient QIljEB; 0 Nursing Home/lTC 0 Hosplc. F.cility
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<br />-..-;;;;'U""" '" "" '"""" ''';, .... .,,,., ""' ..m',,'- - -, ,
<br />st. Francis Medical Center 0 ER/Outpatl.nt 0 D.c.d.nt'sHom.
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<br />[J D:l'\ U Other (Sp.clly)__
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<br />~~I~;dOWi ~ 1~~dc,udezIPcod6"~ 8 0 3 -- -- -"-~d COUNTY OF DEATH Hal ~-- --
<br />8a;:~;::~--LNTY Hall -~ITYORTOWNGra-~~~lan~- -,---
<br />'~tlill,.-9d4TOE4TAN~~d~e~~:--- --=- ~- -rPT,NO \91,2680801" L99'~S~~:_CITY~IM~T;-
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<br />:,,; il~~A;HTAl STATUS AT TIME OF DEAT.H M Marri'd 0 N.v~r Marrl.d lOb, NAME OF SPOUSE (Firsl, Mlddlo, la.t, Suffix) II wilo, givo m.ldon name,
<br />~~ ..1\<
<br />,:~,~ OMarrled,bUlseparat.d OWldow.d ODlvorced OUn,nown Elva Currence
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<br />~'l-';:;;;,,,',:,;;,;;i(,,,.;:-- ----..,;;:--'---;;;;: -,,,;,,, j" "m>~""'~, ------;;;;;;;,;:-- ---,;",," '"m,,"
<br />io',\: Benj amin Franklin Dawso~" _ __ Ma~y Agnes Kretsing~~__
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<br />" 13 EVER IN U S ARMED FORCES? G,VO dat.. ol.orvlc.11 ye0INFORMANT.NAME !4b RELATIONSHIP TO DECEDENT
<br />~~/,grunk) 5-:-2~42 12-30-45 _1___ Elva Dawson _ __ _wife-
<br />15, METHOD OF DISPOSITION 16a~AlMER-SI~T~E "l/J/A -.116b UCENSENO 16c DATE (Mo, D.y, Yr )
<br />e}Runal UDonetlon U ~Mhti-d ---.L1071 Jan. 26, 2007
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<br />U Cremellon 0 Enlombment 160 CEMETERY, CREMATORY OR OTHER-~~N CITY / TOWN STATE
<br />Grand Island City Cemetery, Grand Island, Nebraska
<br />o Removal [J Other (Specity)
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<br />STATE OF NEBR~:A - ~EPAR~~~~rF~~f;~NQ ~U~~N;;~VICES FINANCE AND SUPPORt) 7 _ 2 09 3_~
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<br />.. 5c. UNDER 1 DAY
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<br />HO~:L:INS
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<br />6. DATE OF BIRTH (Mo., D.y, Yr.)
<br />May 1 5, 1 91 6
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<br />,".-..".---......-.--...--
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<br />17a, FUNERAl HOME NAME AND MAiliNG ADDRESS (Str.et, City or Town, Stat.)
<br />All Faiths Funeral Home, 2929 S.
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<br />:: ,)1 '.~r. I
<br />PART I, Enter Ih. cha!JlQI .v.lllill..dl......, injurl.s, or eompllc.llon.nthat directly caus.d the doalh, DO NOT onter tarminel .vents such a. cardiac .rr.st,
<br />rBspiralory arrest I or ventricular fibrillation wllhoul Showing Ihe ellology. DO NOT ABBREVIATE. Enter only one cause on e Iins. Add addltionall1nes if necessary,
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<br />IMMEDIAT~ 99E'."" : on..' to death
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<br />IMMEDIATE CAUSE (Final (a~J!..-vVt~ fl1-71- aA..XI-llAU!..__ _ __ _,__~~- Lt)~e..ejL(J
<br />dlse...orcondltlon resulUng DUE ro, OR AS A COflEQUENCE OF I ons.1 to dosth
<br />Ind.ath) '0 ..' if ". ~ I
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<br />S.qu.ntlally list conditions, II (b)l_Av.(Lll'l,'CC )!A,CU.i/ tl.e4l24f~<-'Z", ._~(:l"'Ca"v::J
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<br />.ny,leedlngtothecsusellst.d - DUETO,OR AS A CONSEQUENCE OF: ....-.-.-/--- - --,--.' I ons.tlod.ath-
<br />on linea. I
<br />Ent.r Ih. UNDERlYING CAUSE I
<br />(dls.... or Injury th.t Inltlat.d (e) I
<br />th..vont...sultlng In death) DUE TO, OR AS A CONSEQUENCE ~ - ..----- -.-- on.et to ci.at;;---.
<br />lAST
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<br />(d)
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<br />18. PART II. OTlUiR SIGNIFICANT CONDITIONS-C~~ditions conl;ibutin9 10 tho doath but nol ro.ultlng in the und.rlying caU.e given in PARn - -r9 WAS MEDICAL EXAMINER -
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<br />() .. ), /7 OR CORONER CONTACTED?
<br />~/{)V (~t/J.JlA-11Tl,..i!.){tZ- _. __ ____ _ [J YE~ !.j..NO_
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<br />20, IF FEMAlE: 21., MAyNER OF DEATH 21b, IFTRANSPORTATION INJURY 21c, WAS AN AUTOPSY PERFORMED?
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<br />o NOI pregnant within pe.t y.ar ^a Natural 0 Homicide 0 Drlver/Opor.tor 0 YES al-11O
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<br />o pr.gnant al time 01 doath 0 AecidentO P.nding Inv..llgation 0 pas.engar -.,..-"----. -..-
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<br />Cl Not pr.gnant, but pr.gnant within 42 days of death 0 Suicide 0 Could not bo determined U Ped.strien 21d. WERE AUTOPSY FINDINGS AVAilABLE TO
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<br />o Not pregn.nl, bul pregnant 43 day. 10 1 year bafore d.ath 0 Othar (Sp.clly) COMPLETE CAUSE OF DEATH?
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<br />o Unknown If pr.gnant within the past year _"._.. ..--. 0 YES 1...loutS/
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<br />-22;;-DATE OF INJU-RY(MO, D.y, Yr) ----EME-OF INJUR:-jpiACE OF INJURY-At hom~,-farm, S1r~~t, factory, ~ffICO building, construcllon Sit., .Ic, (S~- --
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<br />--22d1NJURYATWORK? }:2. DESCRIBE HOW INJURY OCCURRED ---- - - --,- - -
<br />o YES 0 NO
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<br />221. lOCATION OF INJURY. STREET & NUMBER, APT. NO. CITYITOWN STATE ZIP CODE
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<br />23a, DATE OF DEATli (Mo., Day, Yr.)
<br />January 22,2007
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<br />24a. DATE SIGNED (Mo" Day, Yr,)
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<br />24b, TIME OF DEATH
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<br />23c. TIME OF DEATH
<br />10:41 P.m
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<br />24e. PRONOUNCED DEAD (Mo., Day, Yr,) 24d, TIME PRONOUNCED DEAD
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<br />24e. On the basis 01 examination and/or investlgalion, In my opinion death occurred at
<br />tho tim., dale and pl.'. .nd due to th. cause(s) staled. (Signature and Titl.)"
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<br />25, DIDTOti~AC.C..' ...' .S.ECONTR....I.B.UTETOTH.E. DEATH?, ... 2.6.. a,HAS ORGAN O. R TISSUE. DONATION B. EEN CONS. !DERED? .. 26b. WAS CONSENT GR...A. NTEP?
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<br />__ _~S_O_ N~_O .~ROBABlY . iJ'.iUNKN~__ ~_ _ ~ ___ .__ Not AppHc.bl. il 26,=-1~~~YES lJ-.I.t.O'~
<br />27. NAMIl" ...lE AND ApDRESS OF CERTIFIER (PHYSICIAN. r.nRONFR'S PHYSICIAN OR COUNTY ATTORNEY) (Typo or Print)
<br />John Wa oner D 800 Alpha street ,Grand Island, NE 68803
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<br />28., REGISTRAR'S SIGNATURE
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<br />28b, DATE FilED BY REJAir ~ofaY2tl07
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