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<br />WHEN THIs CoPy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HJ:IMANSERVlCES
<br />SYSTEA( ff CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECbllD-.Q/f~ WITH
<br />THE-NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI$TlCS",,#Ct'ON.W~-LS
<br />THE LEGAL DEPOSiTORY FOR VITAL RECORDs. .# J,.S; 'ej L",--Cj
<br />
<br />DATE OF ISSUANCE ~-,'Y7JZ:.v:ttk/'
<br />1/11/2005 ASSJSTANI'stATEM",._ j
<br />LINcOLN, NEBRASKA HEALTH AND Hli!'tAN{i~!f;~1
<br />STAn:: OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERvQs FIN.iJlGi;~SllP1'oR{
<br />VITAL STATISTICS ~-, ,c,,:,,:,',,,,: t\c4'" .
<br />CERTIFICA TE OF DEA TH'..., ,~o.' ;:.,::'.:t/
<br />
<br />200710406
<br />
<br />...'~
<br />
<br />'----
<br />
<br />'- D"C"DENT - NAME
<br />
<br />7. SOCIAL SECURTlY NUMSER
<br />
<br />Hastings, Nebraska
<br />
<br />5iil, AGE. Lilsr Birthday
<br />{YIS,I 53
<br />
<br />Female
<br />
<br />3, 04TEOF OEATH IMonth. Oay. Y.""rl
<br />
<br />14488
<br />
<br />FIRST
<br />
<br />MIDOLE
<br />
<br />LAST
<br />
<br />2. SEX
<br />
<br />4. Crry ANO STAtE OF BIATf.! (II not in u'S.A.. name aOlJntry)
<br />
<br />Brenda Joyce Pittman
<br />
<br />UNOER 1 YEAR
<br />Sb. MOS, DAYS
<br />
<br />UNm,R 1 OA Y
<br />5e, HOURS' MINS
<br />
<br />
<br />December 27, 2004
<br />
<br />6. DATE OF BIRTH (Month. Oay, Y~arJ
<br />
<br />508-60-2376
<br />
<br />July 18, 1951
<br />
<br />8b. FACILITY. Name (If not institution, give street and llumber)
<br />
<br />Inpatient
<br />
<br />~~B: 0 Nursing Home
<br />o AeSldenCt:!
<br />o Other (S~lfVI ~
<br />
<br />L
<br />"1.Ia fl~:::iIU~N~E. ~ I A I E
<br />
<br />- ae. CITY. TOWN OR LOCATION OF OIOATH
<br />
<br />St. Francis Medical Center
<br />
<br />ER Outpatient
<br />
<br />10. RACE ~ (e.g.. White. Slael<. American Indian,
<br />Ole.) ISpeolly}
<br />
<br />11.
<br />
<br />
<br />OOA
<br />
<br />Grand ISland, 68801
<br />
<br />
<br />Hall
<br />
<br />Nebraska
<br />
<br />Hall
<br />
<br />I/,'l,,-i~:.'":~.?it: C:;de,'
<br />
<br />- I 'ile-, !~!SIC'~ CITY l"lfc~ITS
<br />
<br />White
<br />
<br />6888
<br />
<br />Yes [i] No 0
<br />
<br />I
<br />
<br />148. USUAL OCCUPATION /GiV8 kind of work done during mOst
<br />01 working Jile. Sve" If retiredl
<br />laborer
<br />
<br />American
<br />
<br />1:l. NAME OF SPOUSE (If Wile. give maiden ntlmeJ
<br />
<br />14b
<br />
<br />Jesse J. Pittman
<br />
<br />:0
<br />i la. FATHER - NAME
<br />
<br />FIRST
<br />
<br />MIDOLE
<br />
<br />LAST
<br />
<br />manufacturing
<br />17. MOTHER
<br />
<br />(Specify Drily highest grade comp'etedl
<br />Elementary Or Secondary /0-12) College /1-4 or 5"')
<br />12
<br />
<br />415 West 8th Street P.O. Box 204 Wood River, Nebraska 68883
<br />
<br />ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP/
<br />
<br />
<br />MIDOLE
<br />
<br />MAIDEN SURNAME
<br />
<br />~
<br />
<br />Harry Earl Baker
<br />
<br />'" 1 a, WAS DECEASED EVER IN U.S, ARMED FORCES?
<br />!!! (Ye$, no, Or un~.) (If ye:!j:, give war and dates 01 servicesl
<br />NO
<br />
<br />Fern Utecht
<br />
<br />19b. INFORMANT
<br />
<br />MAILING AODRESS
<br />
<br />Jesse J. Pittman
<br />
<br />
<br />4- J~i&r--
<br />
<br />21.. METHOO OF DISPOSITION
<br />
<br />21b. OATE
<br />
<br />~ aurial 0 Rem~val
<br />
<br />Dec 29,2004
<br />
<br />21 c, CEMETERY OR CREMA TORY NAME
<br />Wood River Cemetery
<br />
<br />22b, FUNE;RAL HOME ADORESS (STREET OR RF.D. NO.. CITY OR TOWN. STATe, ZIP!
<br />411 West 11th St. P.O. Box 126 Wood River, Nebraska 68883
<br />
<br />o Crli!rnation 0 Donaflon
<br />
<br />21d. CEMETERY OR CREMATORY LOCATION
<br />
<br />Wood RiVer, Nebraska 68883
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />23. IMMEOIATE CAUS~
<br />PART rr-..
<br />· I lal ~)~ ~
<br />OUE TO, OR AS A CONSEQUENCe OF
<br />
<br />IbJ
<br />DUE TO. OR AS A CONSEOUENCE OF.
<br />
<br />
<br />
<br />~n~~v.~I~~~~!!.~,~.9 dea~~__ _~'_~,,_.,,_
<br />
<br />lei
<br />OTHER SIGNIFICANT CONDITIONS. Condition. COnl"bullng 10 'he de..h bu, not "Ia'ad
<br />PART
<br />/I
<br />
<br />26..
<br />0 ACI;;dent 0
<br />0 SUi(:jde 0
<br />J Homicide
<br />
<br />Undetermined
<br />
<br />2Gb. DATE OF INJURY (Mo" Day. Y'L 26c. HOUR OF INJURY
<br />
<br />27... OATE OF OEATH (Mo.. Oay., Yr!
<br />
<br />Pending 28e. INJURY AT WORK
<br />Investigalioll Yes 0 No 0
<br />
<br />26g, LOCATION
<br />
<br />STREET OR R.ED. NO.
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />27b. OA TE SIGNED
<br />
<br />December 27, 2004
<br />
<br />2S0, DATE SIGNED lMo.. Day. Yr,!
<br />
<br />2ab. TIME OF DEATH
<br />
<br />~~
<br />:~~
<br />'"
<br />~
<br />
<br />
<br />z~
<br />~~r
<br />He>-
<br />8"'~~
<br />.IIffiz
<br />oi6
<br />~ "
<br />o
<br />
<br />260, PRONOUNCEO DEAD IMo.. Day. Y,!
<br />
<br />2ad, PRONOUNCED DEAD (Houri
<br />
<br />M
<br />
<br />~8e. On the basis of ax aminal ion and/or investigalion. in my opinion dealh occurred at
<br />the time. date and place and due to the cau$e(sJ stated_
<br />
<br />M
<br />
<br />John J. Cannella. M.D.
<br />
<br />fryps or Print)
<br />
<br />30,b WAS CONSeNT GRANTED?
<br />DYES
<br />
<br />~O
<br />
<br />REGISTRAR
<br />
<br />Grand Island,Nebraska. 68801
<br />
<br />32b, DATE FILEO BY REGISTRAR (Me.. Day. Y,!
<br />
<br />JAN
<br />
<br />6 200
<br />
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