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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COPYCARRIES 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'MA1~,M ,J~~
<br />DEe 0 7 ZOOl 20071043 4 ::~~~~ll;~~~;A~
<br />LINCOLN, NEBRASKAHEALTIMt"Q"PttJMAN SEfJ1'J9i;.S
<br />f~ ~: ,f ",~ .. .... ,.,.", 10...
<br />~~.. ,."/~~i "~.I~ .' fir : \~. ~
<br />ST., ATE D",F, N",E"BR,ASKA -- DEPARTMENT DF HEALTH AND HUMAN SERVIC,ES.1iJN~N~~S, ~t:e.9lk 1,,;;; 2'" 9 0 7
<br />. _..____ ,_____, ".. CERTIFICATE OF DEATH .,'" '-_,_, ,~.' ill: -Q _ _', ;
<br />1, DECEDENT'S.NAME (First, Middle, Last, Suffix); 2'- !lEX'" ~i?,,) " ~~l"bJ'iltA!.Jj (Mo" Day, Yr,)
<br />,_.~..E5l~;~t Alice Rowse . F~ll1'!:~f :J)lleezdtlep 1, 2007
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE.Last Birthda~I:b' UNDER 1 YEAR 5c: UND~fIIlt2A'fr il,QAl'E OFlliRTH (Mo., Day, Yr.)
<br />.' >
<br />(Yra,) MOS. DAYS HOURS' ~IN~,
<br />Whiterocks, Utah 80 June 29, 1927
<br />
<br />7, SOCIAL SECURITY NUMBER 8a, PLACE OF DEATH
<br />
<br />
<br />524-32-7601
<br />
<br />o Inpatient
<br />
<br />QlliE8: 0 Nursing Home/LTC 0 Hospice Facility
<br />
<br />liQ.Sf'lJAJ.:
<br />
<br />8b, FACILITY:"'NAME (If not instilution, give street and number)
<br />
<br />o ERlOutpatient
<br />
<br />jlIlDecedent's Home
<br />
<br />#19 Via Como
<br />
<br />o [J.}\ 0 Olher (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />
<br />8c, CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />Grand Island 68803
<br />9a, RESIDENCE-STATE
<br />
<br />Nebraska
<br />
<br />9b, COUNTY
<br />
<br />
<br />Hall
<br />
<br />9d, STREET AND NUMBER 91. ZIP CODE
<br />#19 Via Como 68803
<br />lOa, MARITAL STATUS AT TIM-E-OF DEATH )(I Marri~'d'''D Never Married lOb. NAME OF SPOUSE (First, Middle, Last, Sulli.) If wife, ,give maiden name.
<br />
<br />9g, INSIDE CITY LIMITS
<br />
<br />fj, YES 0 NO
<br />
<br />o Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Jack L. Rowse
<br />
<br />", FATHER'S.NAME (First, Middle,
<br />William Lester Flack
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />'2, MOTHER'S.NAME (First,
<br />Ella Marie King
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dates of serviea it yes, '4a.INFORMANT.NAME
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />
<br />No
<br />15. METHOD OF DISPOSITION
<br />
<br />Jack L. Rowse
<br />
<br />16a. EMSALMER.SIGNATURE
<br />
<br />( Not Embalmed )
<br />
<br />, 6d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />18b. LICENSE NO.
<br />
<br />16c, DATE (Mo" Day, Yr. )
<br />December 2, 2007
<br />STATE
<br />
<br />OSurlal
<br />
<br />o Donallon
<br />
<br />~ Cremalion 0 Entombment
<br />
<br />CITY /TOWN
<br />
<br />o Removal
<br />
<br />o Other (Specify)
<br />
<br />Central Nebraska Cremation Service, Gibbon, Nebraska
<br />
<br />______ __.n. .~"'~_._"~".~'
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City orTown, State)
<br />
<br />Kleine Funeral Home, 3213 W North Front
<br />
<br />NE
<br />
<br />
<br />PART l. Enter the chr.tin 01 P.\Jents--dlseases, injuries! or complicalions~-that directly caused the dea.th, DO NOT enter terminal events such as cardiac arrest.
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onsetto death .<t-
<br />
<br />~~.ftt~J
<br />
<br />(aJ .~ -~" tt..~t5~N
<br />DUE TO, OR S A CONSEQUENCE OF:
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or oondlllon resulting
<br />In d..th)
<br />
<br />Sequentially 11.1 oondlllon', It (bJ
<br />any, I.ading 10 the cau..li.t.d -'DUE TO, OR AS A CONSEQUENCE OF:
<br />on IIn...
<br />EntIlrIhe UNDERLYING CAUSE
<br />(dl..... or injury that Inltlat.d (c)
<br />theevenlS resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />lASl"
<br />
<br />I onset to death
<br />
<br />..,._.1_.
<br />I onset to death
<br />I
<br />I
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />18, PART II. OTHER SIGNIFICANT CONDITIONS.Condltlons contributing to the death bul not resultin9 in the underlying cause given in PART I.
<br />
<br />19. WAS MEDICAL ~XAMINER
<br />OR CORONER CONTACTED?
<br />
<br />~~-h-.~; ~? 'f1-. ,.:..;.\.
<br />
<br />
<br />20, IF FEMALE: f\J 1'Ft 21a. MANNER OF DEATH 2'b, IF TRANSPORTATION INJURY 2'e. WAS AN AUTOPSY PERFORMED?
<br />
<br />o Not pregnant within past year .>!qNatural 0 Homicide 0 Driver/Operator
<br />
<br />
<br />o Pregnanl at tima of death 0 AccidentO Pending Investigetion 0 Passenger
<br />
<br />
<br />o Not pregnant, but pregnant wllhin 42 days 01 deelh 0 Suicide 0 Could not be determined 0 Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />o Other (Specify)
<br />o Not pregnant, but pregnant 43 days to 1 year before death COMPLETE CAUSE OF DEATHjJ I
<br />
<br />o Unknown [f pregnant within the past year 0 YES 0 NO I ~
<br />
<br />22a, DATE OF INJURY (Mo" Day:YrJI2,2!lJ),r,t.EOflN,JlJBY___n .22c.$'l.ACE-OF 1H,jl!R'f.,Id'hom',-f.'m, .tre.I~'lactory, office 'building, construction site, elc, (Specify)
<br />
<br />o YES
<br />
<br />J(NO
<br />
<br />CJ YES
<br />
<br />)(NO
<br />
<br />22d.INJURY AT WORK?
<br />
<br />
<br />m
<br />
<br />o YES 0 NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO,
<br />
<br />CITYfTOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a, DATE OF DEATH (Mo" Day, Yr,)
<br />\ 1--\ - 'U:10.:}-
<br />
<br />24e, DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />~~~
<br />"ll~a:
<br />!5:~
<br />~CL iI( ~
<br />"'~z
<br />ll: 0
<br />"'
<br />.2!~5
<br />Ii!a:O
<br />815
<br />
<br />m
<br />
<br />. .- - -n-r---.----~.....~..,.....~..~'~~'~.
<br />23c, TIME OF DEATH
<br />i11<; 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 place and due to the cause(s) stated. (Signature and Title) T
<br />
<br />28b. WAS CONSENT GRANTED?
<br />
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />
<br />Grand Island NE 68803
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo" Day, Yr,)
<br />
<br />DEe
<br />
<br />5 Z007
<br />
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