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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HU~A"t SERVICES \
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL 8~WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSXIC~~~~II4NWbI,/~
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~~ \,,'~'-::'.r'i'.:~:#/:%ii. '
<br />
<br />DATE OF ISSUANCE ' . ~~t, l,
<br />JUN 0 Z 'XInG. -. .~~ ,: TANrEY~. cooPi's-, "
<br />e,uug 4S~rANOTAtE~E"STR~~~
<br />HEA/!#/-LA~MP6ERvICE~ .
<br />. ~', : C":J y'
<br />"~'. -' :r;-, .--'
<br />""; '.'~.. ,'" .. ~,~' .-'
<br />r. '. ~ Sa ~. ,:.... ~ '. . . .... .-.
<br />a;~ ,"'.r..... .......t -t.~~~~" ~\ ~" ~
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES'Flf'It~Cfi... P(j. ~ {>U~P ~ 5 3 0 2
<br />CERTIFICATE OF DEATHt '. .... , ~- (..
<br />2.SEX
<br />Female
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />200805929
<br />
<br />
<br />" DECEDENT'S.NAME
<br />
<br />3. DATE OF DEATH (Mo.. Day, Yr.)
<br />May 16, 2008
<br />
<br />(First,
<br />Sharon
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />SUffix)
<br />
<br />Kay
<br />
<br />Brown
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a. AGE.Lasl Birthday
<br />(Yr5.)
<br />
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6, DATE OF BIRTH (Mo., Day, Yr,)
<br />
<br />April 9, 1943
<br />
<br />Central City, Nebraska
<br />
<br />65
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />505-52-6743
<br />
<br />aa. PLACE OF DEATH
<br />_...!:IOSP.ITAL:. _ __ i! Inp~.ti!nt
<br />a ERlOulpatlent
<br />
<br />WI:JEB: q Nur~~~Q.l-!omelLTC q Hospicefaciiity
<br />
<br />ab, FACILlTY.NAME (If not Institution, give street end number)
<br />
<br />q Decedent's Home
<br />
<br />St. Francis Medical Center
<br />
<br />qOCl',
<br />
<br />q Olher (Specify)
<br />
<br />ac. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island
<br />9a. RESIDENCE.STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />1104 Harrison
<br />
<br />68803
<br />
<br />8d. COUNTY OF DEATH
<br />Hall
<br />
<br />9b. COUNTY
<br />Hall
<br />
<br />
<br />9f. ZIP CODE
<br />68883
<br />
<br />gg. INSIDE CITY LIMITS
<br />:10 YES q NO
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH O{Married q Never Married lOb. NAME OF SPOUSE (Firsl, Middle, Last, SuffiX) If wife, give maiden name.
<br />
<br />o Married, but separated 0 Widowed q Divorced q Unknown Edmund Brown
<br />
<br />I I. FATHER'S.NAME (First,
<br />
<br />Vernon
<br />
<br />Middle,
<br />
<br />Last,
<br />Smith
<br />
<br />Suffix)
<br />Jr.
<br />
<br />12. MOTHER'S-NAME (First,
<br />Audrey
<br />
<br />Middle,
<br />
<br />Malden Surneme)
<br />Gleason
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dales ot service if yes. 14a.INFORMANT.NAME
<br />(Yes, no, orunk.) No Edmund Brown
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />1ab. LICENSE NO.
<br />
<br />16c. DATE (Mo.. Day, Yr. )
<br />May 17, 2008
<br />
<br />16s. EMBALMER-SIGNATURE
<br />Not Embalmed
<br />
<br />o Buriel
<br />
<br />o Donation
<br />
<br />01 Cremation q Entombment
<br />
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />STATE
<br />
<br />CITY / TOWN
<br />
<br />q Removal q Other (Specify)
<br />
<br />Central Nebraska Cremation Service
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS
<br />
<br />Apfel Funeral Horne,
<br />
<br />resplralory arrest, or ventricular fibrillation wlthoutehowlng the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add eddlllonelllnes if neeessery.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />o u,u-.,Jul
<br />
<br />onset to death
<br />
<br />
<br />onset to death
<br />
<br />(a)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Sequontiatly tlSI conditione, If
<br />any, leading 10 tha ceuselllllld
<br />on IIn...
<br />
<br />(b) (t9Ilf)-~C
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />f!)~.sH ~.<:
<br />
<br />
<br />onset to death
<br />
<br />(c)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on5ello dealh
<br />
<br />(el)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in Ihe underlying cause given in PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />q YES q NO
<br />
<br />21 c. WAS AN AUTOPSY PERFORMED?
<br />
<br />o YES ~NO
<br />
<br />20. IF FEMALE:
<br />. Not pregnant within past year
<br />a P,egnent al time of deslh
<br />q Not pregnent, but pregnant wilhln 42 days of death
<br />q Not pregnant, but pregnant 43 days 10 1 year before death
<br />
<br />21e. MANNER OF DEATH
<br />o Natural 0 Homicide
<br />
<br />21 b.IF TRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />q Passenger
<br />
<br />q Pedestrisn
<br />
<br />q Other (Specify)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />q Accidentq Pending Investigation
<br />
<br />q Suicide 0 Could not be determined
<br />
<br />DYES
<br />
<br />!l!I NO
<br />
<br />22b. TIME OF INJURY
<br />
<br />,,______.1__.___
<br />22c. PLACE OF INJURY.AI home, ferm, slreet, factory, office building, oon5truollon site, elo. (Speoify)
<br />
<br />m
<br />
<br />CITYITOWN
<br />
<br />S1J'JE
<br />
<br />ZIP CODE
<br />
<br />m
<br />
<br />~~~
<br />~a:
<br />Il~~
<br />~~~
<br />1!~o
<br />~a:O
<br />8a
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />24C. PRONOUNCED DEAD (MO., Dey, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e, On the basis of e..mlnetlon and/or Investigation, in my opinion death occurred al
<br />the lime, dale end place and due to the cause(s) slated. (Signature and Title) 'f
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b, WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO q YES Ii NO
<br />
<br />q YES (J:NO q PROBABLY 0 UNKNOWN 0 YES Xl NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Brant L. Luebbe M.D. 820 N. Al Grand Island,
<br />
<br />NE 68803
<br />
<br />~\I
<br />
<br />28e. REGISTRAR'S SIGNATURE
<br />
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo.. Dey, Yr.)
<br />
<br />MAY 2 0 Z008
<br />
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