|
<br />)
<br />
<br />STATE OF NEBRASKA
<br />
<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 />
<br />::::'~:~:;:RY FOR YITAL RECORDS. . ~ilfIJJ'~
<br />
<br />OCT 15 2007 ASS/~l:A~t:;M~;:
<br />LINCOLN, NEBRASKA 2 0 08 0 6 0 2 6 HEAL!,,!~Ntiii!lMfft,~s
<br />.~ ~""'" ~"!~'>r:ir':\:", ,~"":
<br />
<br />i ~ :. ~,~ ,.~:."~'"....~, ,~. ~
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES -FINAlIl~ AND Si,JPPQ T"':
<br />_ CERTIFICATE OF DEATH -::.....,.':," ,'; ~,/ , 3,
<br />
<br />IFirst, Middle, Last, Suffix) 2_ SEX '~~":~E-dl:'bp'tH (Mo" Day, Yr,)
<br />
<br />
<br />Rockport. MO
<br />7_ SOCIAL SECURITY NUMBER
<br />505-29-3032
<br />FACILITY-NAME (If not Institution, give street end number)
<br />
<br />5e, AGE-Last Blrlhday 5b, UNDER 1 YEAR
<br />(Yrs,) 90 MOS, DAYS
<br />
<br />
<br />June 17. 1917
<br />
<br />ea_ PLACE OF DEATH
<br />
<br />1:iO.SfJIAl.:
<br />
<br />~ Inpatient
<br />
<br />QlliER Cl Nursing Home/LTC Cl Hospice Facility
<br />
<br />CJ ERlOutpatient
<br />
<br />CJ Dacedent's Home
<br />
<br />'- St. Francis Medical Center
<br />
<br />CJ[U',
<br />
<br />Cl Other (Specify)
<br />
<br />Sc_ CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island
<br />
<br />Sd, COUNTY OF DEATH
<br />Hall
<br />
<br />9a, RESIDENCE.STATE
<br />Nebraska
<br />
<br />9b, COUNTY
<br />Hall
<br />
<br />
<br />. Merried CJ Navor Married
<br />
<br />1 Db, NAME OF SPOUSE (First, Middle, Leat, Suffix) If wlfo, give meidan nama,
<br />McMindes
<br />Annabel Melita
<br />
<br />CJ Divorced CJ Unknown
<br />
<br />Middle,
<br />
<br />Lest,
<br />
<br />Suffix)
<br />
<br />12, MOTHER'S.NAME IFlrst,
<br />Ruth Louder
<br />
<br />Middle,
<br />
<br />Malden Surneme)
<br />
<br />13, EVER IN U,S, Ai'tj~g>~~Ef/rv~ ~~~z:;vica it yes, 14e,INFORMANT.NAME
<br />(Ye.,~o,orUnk,)_ Yes Annabell Houts
<br />15, METHOD OF DISPOSITION 16a, EMBALMER.SIGNATURE
<br />o Burial o Donallon Not Embalmed
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />
<br />~C'emation 0 Entombmant
<br />
<br />16d, CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />EENSE NO,
<br />
<br />
<br />CITY / TOWN
<br />
<br />Wife
<br />16c, DATE (MO" Day, Yr, )
<br />
<br />Se tember.18 2007
<br />STATE
<br />
<br />o Ramoval ClOthar(Specily) Westlawn Memorial Park Crematory. Grand Island. Nebraska
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS ISlreet, City or Town, Stata)
<br />Livingston-Sondermann Funeral Home.
<br />
<br />IMMEDIATE CAUSE (Flnal
<br />dl..... oroondltlon ,,",ultlng
<br />In_)
<br />
<br />PART I. Enler the chain of avenlsudi'eases, injuries, or complications--that dlraclly caused the death, DO NOT enler tarmlnel avents such aa cardlec erre.t,
<br />rasplralory arre.t, or ventricule, librillation without showing the etiology, DO NOT ABBREVIATE, Enter only one cause on eline, Add additional lines If nacassary,
<br />IMMEDIATE CAUSE: ,"--.f'J
<br />
<br />~_._l\g \'r~
<br />
<br />DUE TO, OR AS A CONS ENCE OF:
<br />
<br />
<br />::,,:~~:::!~,"J;,~ ~L
<br />
<br />(e)
<br />
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />
<br />onset to death
<br />
<br />Sequentially 1I.t oondltlons, if
<br />any, leedlng to the cau..1l1ted
<br />onlln.a.
<br />EnlBrthe UNDERLYING CAUSE
<br />(df..... or Injury that Inltfato<!
<br />theevenla reoulllng In doath)
<br />LAST
<br />
<br />onset to daath
<br />
<br />
<br />.L~
<br />
<br />onset to dealh
<br />
<br />(d)
<br />
<br />o Not pregnant within past year
<br />Cl pregnent at time 01 death
<br />CJ Not pregnant, but pregnenl within 42 days 01 death
<br />o Not pregnent, but pregnant 43 days to I year bafore death
<br />o Unknown if pregnenl within the pe.f yeer
<br />
<br />/la,eNNER OF DEATH
<br />,JlII..Natural Q Homicide
<br />
<br />a AccidantO Pending Investigation
<br />
<br />CJ Suicide 0 Could not be daterminad
<br />
<br />19, WAS MEDiCAL EXAMINER
<br />
<br />Iii OR CORONER CONTACTED?
<br />
<br />a YES 0
<br />
<br />21 b, IFTRANSPORTATION INJURY 21c, WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator "- \--""0
<br />o Passenger 0 YES ;x.:'
<br />
<br />l:l Pedestrian
<br />o Olher (Specify)
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />a YES 0 NO
<br />
<br />22a_ DATE OF INJURY IMo" Day, Yr,)
<br />
<br />22b, TiME OF iNJURY 22c, PLACE OF INJURY-At home, tarm, straal, factory, office building, construction site, etc_ (Specify)
<br />m
<br />
<br />22d, INJURY AT WORK?
<br />
<br />22a_ DESCRIBE HOW INJURY OCCURRED
<br />
<br />CJ YES 0 NO
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO,
<br />
<br />CITYrrOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a_ DATE OF DEATH (Mo" Day, Yr,)
<br />Il
<br />
<br />24a, DATE SIGNED (Mo_, Day, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />!'~r
<br />J~~
<br />fg~~
<br />llZ=>
<br />00
<br />t2a:CJ
<br />Be
<br />
<br />m
<br />
<br />24c, PRONOUNCED DEAD IMo" Day, Yr.) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e, On the basla 01 examination and/or Investlgalion, in my opinion daath occurred at
<br />Ihetima, date and piece and duato the ceuaa(s) statad_ ISignature and Tille) ...
<br />
<br />e, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? p{6b_ WAS CONSENT GRANTED?
<br />Not Appllceble il 26a is NO CJ YES 0 NO
<br />
<br />Grand Island NE 68802
<br />
<br />2Sb, DATE FILED BY REGISTRAR IMo" Day, Yr,)
<br />
<br />
<br />2007
<br />
|