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<br />
<br />STATE OF NEBRASKA
<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 />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~.. J," /I ~ '.
<br />
<br />DATE OF ISSUANCE ,0; CA1V8'"
<br />JAN 2 9 TAIYL.EyIS. COOPER
<br />2008 2 0 0 8 0 0 8 5 7 ASSISTAIt,T S'rATE'REGJ$TRAR
<br />LINCOLN, NEBRASKA HEALTH 4NQ ilfJMAN SERVICIES
<br />......, ," .J.... ''11:.'\''" "/
<br />
<br />",.
<br />
<br />
<br />~~'. - ~
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERvicES FINANoEAND SUPF>
<br />CERTIFICATE OF DEATH-
<br />
<br />
<br />4.83_,_
<br />
<br />_,~;~;e ;I:~ ~:~;~:' Suffix) . i~' '~~;~al~~'-:-
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH M. 'AG.E.last Birthday ~~~R1 YEA~ :~~N[jER \ DAY
<br />J!:",,) , MOS, r DAYS' ....t/Ol.lRlJ 'T.ml$',
<br />Mud Lake, JdaFR>>__'__.' ..' 87 I '. ... .'
<br />
<br />7, SOCIAL SECURITY NUMBER lla, PLACE OF DEATH
<br />
<br />3. DATE OF DEATH (Mo" Day, Yr.)
<br />
<br />February 22, 2007
<br />
<br />6, DATE OF BIRTH (Mo" Day, Yr,)
<br />
<br />February 9, 1920
<br />
<br />506-28-0031
<br />
<br />~:
<br />
<br />LJ Inpatiant
<br />
<br />OTHER il. Nursing HomelL TC D Hospica Facility
<br />
<br />..----------..
<br />8b, FACILITY NAME (II not Institution, glva street and number)
<br />
<br />[J ERlOutpatient
<br />
<br />[] Dece<lenrs Home
<br />
<br />Beverly Healthcare Park Place
<br />
<br />,.J~OUNlY
<br />
<br />Hall
<br />
<br />["I DOA D Othar(Specify)__,
<br />.. "--~,y-OF DEATH Hall
<br />
<br />
<br />I. 9c, CITY OR TOWN Cairo
<br />
<br />
<br />. --'~ Qe. APT. NO, -t~:~~~~,24
<br />
<br />1Ob, NAME OF SPOUSE (First, Middle, Last, Suffix) If wita, give meiden name
<br />
<br />9g, INSIDE CITY LIMITS
<br />DYES lllI NO
<br />
<br />Be. CITY OR TOWN OF DEATH (Include Zip Coda)
<br />Grand Island, 68803
<br />
<br />D MarTiad, but seporotad IXIl11r1dowe<l D Divon::ad D unknown
<br />
<br />Leo Quaring
<br />
<br />--;'~ATHER'S.NAME--(F;;.t,- Ch:~:~ NOrdst~;~ .", s~:~ 12. MOTHER'S~:E'
<br />
<br />13, EVER IN U.S, ARMED FORCES7 Glvo dotes of service Ifyas. 148. INFORMANT NAME
<br />(Yes, no, or unk.) NO
<br />.-',,-.- ."---'---'--
<br />15. METHOD OF DISPOSITION
<br />
<br />(FIf1It,
<br />
<br />Middle, Maiden Surname)
<br />Sophia Johnson
<br />'l";4D RELATI~:SH;;~ DECEDENT
<br />
<br />
<br />116<:. DATE (Mo., Day, Yr.)
<br />February 26, 2007
<br />
<br />STATE
<br />
<br />I1iilBurial
<br />
<br />[l Donetion
<br />
<br />Marlin Quaring
<br />168 EMBALMER~IGNATURE. ~ _;~=116b LICENSE ~;;2r
<br />
<br />ffid-:-CEMErERY.~~::V O~ER LOCATION' ,--- CITYITOWN--' , --~-'--
<br />
<br />D CIllmotlon lJ Entombment
<br />
<br />o Removal D Other (Specify)
<br />
<br />Mt. Pleasant Cemetery
<br />
<br />Cairo
<br />
<br />Nebraska
<br />
<br />._ _ ._."...,_.__.._._._.""..".__~._."..~.L __.~"~.__~_.__.
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home 411 West 11th St. P.O. Box 126 Wood RIver Nebraska
<br />
<br />IMMEDIATE CAUSE
<br />
<br />oMetto death
<br />
<br />IMMEDIATE CAUSE (Final
<br />d..... tJof fi,ondttklO ...sultlng
<br />I._I
<br />
<br />~A-A(c.t /J
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Ai; \,
<br />
<br />~Y6'
<br />
<br />I onset to d...th
<br />I
<br />I
<br />I
<br />I onset to death
<br />I
<br />I
<br />I
<br />
<br />'r;;;;-setto death
<br />I
<br />I
<br />~ I
<br />
<br />-18 PART II OTHER SIGNIFICANT CONDITIONS-:C~~dlti";"~';""tributlng to the death but nol_ulting In tha UnderiYI.,g cau~ given In PART I, TI' 19 WAS MEDICALEAAMlNER
<br />OR CORONER CONTACTED?
<br />
<br />o YES ~NO
<br />---------------- - " - - -- --- - ------ ~.
<br />20. IF FEMALE: 210. MANNER OF DEATH 210. IF TRANSPOflTAllON INJURY 21C. WAS AN AUTOPSY PERFORMED?
<br />~ I-D~ D~~~
<br />.rot pregnant within past yoer 0 YES ~O
<br />[J Pregnant at timo of death AcadentDPendlng Investigation n Passenger
<br />D Pedestrten
<br />
<br />s.quenttllty list Cl)nditiol'l&, ..
<br />_ny, IMdlng to the CIIU_ I~
<br />an 11M ..
<br />Enloo.... UNDERL VlNO CAUSE
<br />(dlMaH or Injury that Inttidld
<br />the evlints lHuldng IP dNth)
<br />lAST
<br />
<br />(b)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(c)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />U Not pregnant, but pregnant within 42 days 01 death
<br />
<br />d SuiCide [JCould not'be'delarrninad
<br />
<br />21d. \/\/ERE AuloPSV FINDINGS AVAIlABLE TO
<br />
<br />D Not prognent, but pregnant 43 days to 1 year before death _,__~', , .. __
<br />nliiePallYe8r' U YES n NO
<br />-22a-:DATE Oi"INjUR'{('Mo, Day, Y0t' TIME OF INJU: 22C. i>lA'CE-OF INJURY.At hOf1ie. I~rm, Slt88l, lactory, office bUilding, oonstructlon Site, ate (Specify)
<br />
<br />22d INJURY AT WORK? L;-OESCRiBE HOW INJURY OCCURRED
<br />LJ YES 0 NO
<br />- ---- - ------ --_".'.~"'.~._"._'_._-"'''..' ".-,.------...-.
<br />221, LOCATION OF INJURY - STREET & NUMBER, APT. NO, CITYffOWN STATE
<br />
<br />D Other (Specify)
<br />
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />ZIP CODE
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />~1ii
<br />~y~
<br />dc~
<br />~i5~"
<br />u~::>~
<br />" 0
<br />.a ..,
<br />~8li
<br />
<br />m
<br />..- .-.... ..,.-- .-.,
<br />24c;. PRONOUNCED DEAD (Mo.. Day. Yr.) 24d. TIME PRONOUNCED DEAD
<br />
<br />m
<br />
<br />248, On the besls of my examination and/or investigation, in my opinion death occulNd at
<br />thO time, date and pi""" and due to tha cause(s) stated. (Slgnatulll Ond Time) T
<br />
<br />DYES '-P}lO 0 PROBABLY D UNKNOWN D YES ~
<br />~27~NAME~ND'AOORESS OF CERTIFlliR (Physician, CORONER;S-PHYSICIAN OR COUNTY ATTORNEY) (Typa or Prirlt)
<br />David Colan M.D. 729 N. Custer Ave., Grand Island, NE.
<br />
<br />26b, WAS CONSENT GRANTED?
<br />D .YE~ NO
<br />
<br />Not Appllcebla If 260 Is NO
<br />
<br />68803
<br />
<br />
<br />28b. DATE FILED BY REGISTRAT (Mo., Day, Yr.)
<br />
<br />MAR
<br />
<br />7 2007
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