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<br />STATE OF NEBRASKA
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<br />DATE OF ISSUANCE
<br />APR 1 5 2008
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<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 RECrJRO-oN-F.JLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI$TICS 1lEft.C.1'IOI1.JytJnpI'lIS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <'. ':.... -.'. _. .j/. J c .i
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<br />LINCOLN, NEBRASKA
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<br /> STATE OF NEBRAS~F DEPARTMENT OF HEALTH AND HU~R~;i,~~~~~j'~5
<br /> :RTll-llOA II:: OF I It-A I H . __ .,'~ '.. ." .
<br />I~~ 1. OECEOENT'S-NAME (FI..t, Middle, Leaf, sumx) 2.$@11, -~l: . . . "~T~ . . . . o.,Oly,Yr.)
<br /> ~..JU! IV ~" ...~,..T
<br />\) Pearl NMI Gidmond Fern"" ",' 'ApIn.t~8
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 51. AGE.lIlt Blrthdly 5b. UNDER 1 YEAR k.UNOERJ~Y ,~l:1j OF BIRTH (Mo.. OIy, Yr.)
<br /> (Y...) MOS. T DAYS " HOURS I MIN$.' "'! .
<br />I Arapahoe. Nebraska 89 July 10,1918
<br />I 7. SOCIAL SECURITY NUMBER 81. PLACE OF OEA TH
<br />rr: 508-28-0626 ~ IXIlnpatilnt 2IJ:Wl: 0 Nu..lng Home/LTC D HOlplce Flclllty
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<br />l- 8b. FACILITY-NAME (II no'lnslllu.lon. give slree'snd number) D ERlOutp.tient o O.eed.':It'. Home
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<br /> Saint Francis Medical Center DOOA OOlh.rjSpeclfy)
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<br /> 8c. CITY OR TOWN OF DEATH (Include Zip Code) 18d. COUNTY OF DEATH
<br />~~ Grand Island 68803 Hall
<br />;:J B., RESIDENCE-STATE lib. COUNTY I'c. CITY OR TOWN
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<br />j Nebraska Hall Grand Island
<br />'I:l Id. STREET ANO NUMBER 1Be. APT. NO. /If. ZIP COOE IBg. INSIDE CITY LIMITS
<br />c! 2624 W. Lamar Ave. 68803 Il!l Yes 0 No
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<br />i 101. MARITAL STATUS AT TIME OF DEATH iii M.med D Never M.rried/10b. NAME OF SPOUSE (FI..~ Middle, LII~ Sufllx) "wit., gl.e molden n.me.
<br />D M.rried, but .eplrlled 0 Widowed D Divorced D Unknown Francis W Gidmond
<br />i5. 11, FATHER'S-NAME (FI..~ lI.., Sumx) r 12. MOTHER'S-NAME (FI"I,
<br />E Middle, Middle, Mllden Sum.me)
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<br />0 LeRov Trunnell Sarah Hand
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<br />aI 13. EVER IN U.S. ARMED FORCES? Give dlt.. of ..nIlce If Y"114S. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
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<br />l- (Ye.. No, or Unk.) No Francis W Gidmond Husband
<br /> 15. METHOD OF DISPOSITION ~::R::NATURO ~Ltf~..tl 18b. LICENSE NO. 15c. DATE (Mo., o.y, Yr.)
<br /> (i) Burial DnonoUon I~ 97 April 11, 2008
<br /> o Cremation OEntombment 18d. tEMETERY, CREMATORY OR OTHER LOCATION STATE
<br /> o RMIIDV.I OOlil.~S...i1.) CITYfTOWN
<br /> Grand Island City Cemetery Grand Island Nebraska
<br /> 171. FUNERAL HOME NAME AND MAILING ADDRESS (Stree!, City or Town, Stole) 17b. Zip Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> /. CAUSE OF DEATH (See instructions and examDles)
<br /> 11. PART I. Entf:r the el1./n tit ltVOlils . diM..... Il'IjuriU;, or- cDIJI~II;"'on.... that dll1lctly .:tiu"-' tM dnth. 00 t.lOT tln"(" ..rmtnll.vents .uc.h as cal'd--= 1mI.1. I APPROXiMATE
<br /> INTERVAL
<br /> ,..pl,,-lory a.......t. Of vel1tril::ul.r tlbrlllMlon wrthout lhowlng 1M BloIItGY. Do MoT AIIBleVlA.TIIi.. ~r on'y one ClUM' c:tn. 11M. Add addltioMlllnu if ~.auy. I
<br /> .- ' .~ lMMIiIlIoUeilAUSE: ". 0;'10110 ~.111
<br /> IMMEDIATE CAUSE IFln11 \-.\ eM'\/< ll~ '-' C!.Q.J\.i1.. ~~} Cl.C{: ',duct I d4-- k-M
<br /> dl..... or condition rwsultlng I) v.'L~ ~"- I
<br /> In delll1)
<br /> "" I on.ellO del'"
<br /> DUE TO, OR AS A CONSEQUENCE OF:
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<br /> Sequenti.lly II.t conditions, If b) I
<br /> any, leading to the co.us. listed
<br /> on line a. DUE TO, DR AS A CONSEQUENCE OF: I on... 10 d..til
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<br /> Enl.r th. UNDERLYING CAUSE c) I
<br /> (dl....e or Injury thlt Inltilled DUE TO, OR AS A CONSEQUENCE OF:
<br /> "'e .v.n.. resulting In de..iI) on... to delll1
<br /> LAST I
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<br /> d) I
<br /> 18. PART II. OTHER SIGNIFICANT CONDITIONS.condltion. conll1buting to Ill. d.11I1 but not relulting In lI1e underlying Clu.e given In PART I. 11. WAS MEDICAL EXAMINER
<br /> D~o'h'~ OR CORONER CONTACTED?
<br /> DyES j&)NO
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<br />I1l 20. IF FEMALE: 21.. MANNER OF OEATH 21b.IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />ii: ~ No. pregnen' within past yelr ~N.lurll ~NO
<br />~ D Homicide D DrlverfOpe..tor DYES
<br />I1l D Preyn"l It time of d..", o Accldenl D P_lng In...tig.tion o P....ng.r 21d. WERE AUTOPSY FINOINGS AVAiLABLE
<br />0 o No' pregnlnl, bul pregn.nt wlll1ln 42 de,. of dee'" D Sulcldl o Could not be d."nnlned . 0 Pod..lrl.n
<br />j TO COMPLETE CAUSE OF DEATH?
<br />o Not pregn..~ but pregnlntC d.y. to 1 yelr before de.'h D Oll1er (Specify) DYES DNO
<br />]I DUnl<n_n if pregn..1 wllhln the p..t ye..
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<br />j5. I 22b. TIME OF INJURY T 220. PLACE OF INJURY-AI home, flnn, .Iree~ feclory, omce building, cone_tion .1... ele. (SpeCify)
<br />E 221. DATE OF INJURY (Mo.. D.y. Yr.)
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<br />ID 22d~~:Y ~~:R:122e'_DESCRlBE HOW INJURY OCCURRED
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<br /> 22f. LOCATION OF INJURY. STREET & NUMeER, APT. NO. CITYfTOWN STATE ZiP CODE
<br /> 23.8. DATE OF DEATH (Mo., D.y, Yr.) lr'~~ 2411. DATE SlGNEO (Mo.. OIy, Yr.) 241>. TIME OF DEATH
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<br /> 23b. OATE SIGNED (Mo., D.y, Yr.) T 23c. TIME ~TH JIIlO 240. PRONOUNCED DEAD (Mo., D.y, Yr.) 24<1. TIME PRONOUNCED DEAD
<br />j .l!!~>- L{ -' lr -{) ~ o :tDtI..m ~I= >-
<br />......... ...a..<( ~
<br />e ""z 15~~0 m
<br />8,,0 23d. To "'e be.. of my knowledge. del'" occurred .'Ihe time, dl.. ..d pl.ce u.. On th. b..la of examination .ndlor Inve..tlg<<tlon, In my opinion de.th occurred
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<br />Indduel;z:e(~~ ..Z~ .'lI1e time, dlte Ind pl.ce.nd due to the clu.e(l) '''Ied. (Slgnlture Ind Tille)
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<br /> 25. DID TOBAC~ USE CONTRIBUTE TO THE DEATH? 1288. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? "I' 28b. WAS CONSENT GRANTED?
<br /> D YES NO D PRoeABL Y D UNKNOWN DYES iXI NO No' Appllclble If 281 Ie NO 0 YES DNO
<br /> ~. NAME, TITLE AND A~~SS OF C~RTIFIER (PHYSI~IAN, CORONER'S PH~SICIAN OR COUN~ ATTORNEY) (Type or Prln.) l\lB (p ~ K 03
<br /> e\:)aCtA_ '-2-e'\{\\L,{,..,,~ dl\ll vJ H>...H~';1. Sud-e t.{()O Gn\.V\A:I:-& (p..V\.d
<br /> 281. REGISTRAR'S SIGNATURE ~~/- A r~ 28b. DATE FILED ey REGISTRAR (Mo., Day, Yr.)
<br />p APR 1 1 2008
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