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<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTI1-AlJIfj~,SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINJtt P'(~l}(Q;.l~ WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL srJ.f/~i~sJicrL~N.Yll!.fl~ IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. :;' ,':......-~;..4- ~.~.. '''':.: g,
<br />",' ~f.
<br />DAA~RE OF ISSUANCE 20080 Q t oih ~I ~: _L"" N;'~. c~~~~
<br />M 0 4 2008 "',.,,, < ~SSISTiD/ iflTEJ1EpIS,~Ij)
<br />LINCOLN, NEBRASKA 1f~,fTH AND HUMAN SEtt\titJE~
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<br /> 1 " ,. !'17 ...:.
<br /> STATE OF NEBRASKA. DEPARTMENT ~;EAL TH AND HUMAN'\F.~:~ blA"'.~~l{8i/
<br /> ~~K DEATH1-~a. .' r.. . ,
<br />\ 1. DECEDENrS-NAME (Flrol, Mlddl., Lust, Suffix) 2.SEX ~i 'F, e EVE.~F DEA1"J.t!t.lii:,D.Y.Yr.)
<br /> ~'"
<br /> I Gloria Jean Fisher Female ... ~rebFuarv25, 2008
<br /> 4. CITY AND STATE O~ TE~IijTO~Y. O~ FOREIGN COUNT~Y OF BI~TH 5.. AGE.L..t Blnhd.y 5b. UNDE~ 1 YEA~ 5c. UNDE~ 1 DAY 5. DATI! OF BIRTH (Mo., D.y, Yr.)
<br /> (Y.....) MOS. I DAYS HOUM I NIINS.
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<br />i Grand Island, Nebraska 61 November 19, 1946
<br />j 7. SOCIAL SECUIijTY NUMBER Sa. PLACE OF DEATH
<br />505-64-1384 ~ 0 Inp.,I.nl ~ 0 Nu....lng Hom./L TC o Ho.plc. F.clllly
<br />5b. FACILITY-NAME (If nolln.lllullon. gly. .,.... .nd numb.r) o ER/Oulp.lI.nl iii D.c.d.nl'. Home
<br />4064 Stauss Road OOOA o OIh.r(Sp.clfy)
<br />15
<br />-' 8c. CITY o~ TOWN OF DEATH (Includ. Zip COd.) 15d. COUNTY OF DEATH
<br />~ Grand Island 68803 Hall
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<br />z aa. ~SIDENCE-STATE lab.coUNTY I 9c. CITY O~ TOWN
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<br />~ Nebraska Hall Grand Island
<br />"g ad. ST~EET AND NUMBE~ I a.. APT. NO. 191. ZIP CODE I 9g. INSIDE CITY LIMITS
<br />.!l! 4064 Stauss Road 68803 o Y.. iii No
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<br />ell 10.. MA~ITAL STATUS AT TIME OF DEATH iii M.rrI.d o N.ver M.rrI.dl lOb. NAME OF SPOUSE (FlraL Mlddl., L"L Sumx) II wi'., give mald.n n.m..
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<br />1! o M.rrled, but ..por.tad 0 Wldow.d o Dlyorc.d o Unknown Rodnev Fisher
<br />Q, 11. FATHE~'S.NAME (Firat, Middle, sumx) -r 1 2. MOTHE~'S-NAME (FlraL Middle, Maiden Sum.me)
<br />E L..L
<br />0 Maroaret Isebem
<br />u Marvin Beberniss
<br />ell 14b. RELATIONSHIP TO DECEDENT
<br />lD 1 3. EVE~ IN U.S. A~MED FO~CES? GIY. d.te. of ..IVlce "ye.'1 14.. INFO~MANT -NAME
<br />{:. (Y.., No, or Unk.) No Rodney Fisher Husband
<br /> 15. METHOD OF DISPOSITION 16.. EMBALMER-SIGNATU~E I lab. UCENSE NO. 16c. DATE (Mo.. Day, Yr.)
<br /> o Burial o Donauo. Not Embalmed February 26, 2008
<br /> iii CrematiOn OEntombnHllnt 16d. CEMHE~Y, C~EMATO~Y O~ OTHE~ LOCATION CITYITOWN STATE
<br /> o Removal OOU1a~Bpa.lIy)
<br /> Central Nebraska Cremation Service Gibbon Nebraska
<br /> 17.. FUNEML HOME NAME AND MAILING ADD~ESS (Str.oL CUy or Town. Statal 17b. Zip Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> CAUSE OF DEATH(See instructions and examples)
<br /> 11. PART I. Enter the chain oI.vents & dl....M., InJurl.a. Dr {;Ompllc8tlonll. thllt ctlree1:ly c",u..d the dtatn. DO NOT .nter tennlnalewntll lIuch .. c.rcU.e ......st, I APPROXIMATE
<br /> INTERVAL
<br /> ....plllltory am.t, Dr ventricular f1brU!.tlon without showing the .UoIQ~Y. DO NOT ABBREVIATE. Entll:r anly on. eaute on a Ii,.... Add *ddltlonaIIIM. tf n.c....ry. I
<br /> - IMMEDIATE CAUSE: .- - onaot to d..1h
<br /> IMMEDIATE CAUSE (Fln.1 1!{4/bfIJ~~ ~C~p~ ///--.d I
<br /> dl....e or condition resulting .) I
<br /> In deeth)
<br /> DUE TO, O~ AS A CONSEQUENCE OF: / I Onset to death
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<br /> Sequentially list conditions, If b) I
<br /> any.l.ading to the causeU,ted
<br /> on line .. DUE TO. O~ AS A CONSEQUENCE OF: I on..t to d..th
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<br /> Ent.r tho UNDE~L YING CAUSE c) I
<br /> (dl..... or InjurY thet InUI.tod DUE TO, O~ AS A CONSEQUENCE OF: ' on..t to d..th
<br /> the eventa ruaultlng In d..th)
<br /> LAST I
<br /> I
<br /> d)
<br /> 18. PART II. OTHE~ SIGNIFICANT CONDITIONS.condlllonB conlrlbullng to IhB d..th but not re.uillng In tho undorlylng c.u.. gly.n In PART I. 19. WAS MEDICAL EXAMINER
<br /> O~ CO~ONE~ CONTACTED?
<br /> DYES [j-1<JO
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<br />W ~ FEMALE: 21.. MANNE~ OF DEATH 21b.IF TMNSPO~TATION INJU~Y 21.. WAS AN AUTO~FO~MED?
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<br />j:: Not pregnant within past year o N.tur.1 o Homlcld. o DrI.or/Operotor o YES NO
<br />tt: o pregn.nt .t 11m. 0' d.eth o Accld.nt 0 Pondlng In...llg.lIon o P....nger
<br />W 21d. WE~E AUTOPSY FINDINGS AVAILABLE
<br />U o Not pregnant. but pregnant within 42 days of death o Sulcld. o Could not be d.tennlned OPed..lrlon
<br />~ TO COMPLETE CAUSE OF DEATH?
<br />o Not pregn.nt. but pregnant 43 days to 1 ye.r before d..th o Oth.r (Specify) DYES ONO
<br />"g OUnknown If pregnant within the past year
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<br />Q, I 22b. TIME OF INJURY 1 22c. PLACE OF INJU~Y.At home, fenn, .traoL '.ctorY, omc. building, .on.trucllon .110, .tc. (Spoclfy)
<br />8 22.. DATE OF INJU~Y (Mo., D.y, Yr.)
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<br />ell
<br />lD 22d. INJU~Y AT WORK? 220. DE5C~IBE HOW INJU~Y OCCUMED
<br />~ DYES ONO
<br /> 22'. LOCATION OF INJURY. STREET & NUMBE~. APT. NO. CITYITOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., D.y, Yr.) Z 248. DATE SIGNED (Mo.. D.y, Yr.) Z4b. TIME OF DEATH
<br /> Z ~S;~
<br /> ~S; March 25, 2008 uz m
<br /> ...sz ~l;:i~M~Y' Yr.) J;;;~
<br /> ~~>- 1 23c. TIME OF DEATH ~I= >- 240. P~ONOUNCED DEAD (Mo., D.y, Yr.) 24<1. TIME P~ONOUNCED DEAD
<br /> c..:I:...J 3:00 p. m. ~:;o( ...J
<br /> eP.z m
<br /> 0"0 o iI:~ ~
<br /> u.!: - ,.~~._._--- 248. On th8 bDla of .xamlnatlon and/or Inv.stlgatlon, In my opinion death occurred
<br /> .tog "w
<br /> I$~tat)'d. gn. re.ndTlllo) h-c- 1:255 at the time. d.t. and place .nd due to the c.use(s) stated. (Slgnlture and Title)
<br /> ~~ - . 'l ./ .J// "'!, ~a::U
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<br /> 26.~BACCO USE CONTRIBUTE TO THE DEATH? 12a.. HAS O~GAN OR TISS~ATION BEEN CONSIDE~ED? 12Gb. WAS CONSENT G~NTED7
<br /> YES 0 NO 0 PROBABLY 0 UNKNOWN o YES NO Not Appllc.blo If 29a I. NO 0 YES ONO
<br /> 27. NAME, TITLE AND ADD~ESS OF CE~TlFIE~ (PHYSICIAN, CO~ONE~'S PHYSICIAN O~ COUNTY ATTORNEY) (Typo or Print)
<br /> William J. Lawton M.D., 2444 Wa Faidlev Ave. . Grand Island, Nebraska 68803
<br />, 2a.. ~EGISTRAR'S SIGNA TU~E Att- /~/i~ 1. (~. 2Gb. DATE FILED BY ~EGISTMR (Mo., Doy, Yr.)
<br /> ; MAR 3 2008
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