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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />CERTIFICATE OF DEATH
<br />
<br />328265
<br />
<br />1. DECEDENT'S.NAME (FIn/I, Middle.
<br />Carol Yvonne Con rove.
<br />4. CITV AND STATE DR TERRITORV, OR FOBEIGN COUNTRY OF BIRTH
<br />
<br />losl,
<br />
<br />Sulflx)
<br />
<br />2. SEX
<br />
<br />Female
<br />
<br />60. UNDER t DAV
<br />HOURS MINS.
<br />
<br />3. DATE OF DEArH (Mo" Day, Vr.)
<br />October 11, 2007
<br />8. DATE OF BIRTH (Mo.. Day. Vr.)
<br />
<br />6a. AGE-laol Blrlhdoy 5b. UNDER 1 VEAR
<br />(Vro.) MOS. DAYS
<br />
<br />Clay County, Nebraska
<br />
<br />7. SOOIAL SECURITY NUMBER
<br />
<br />506-32-1220
<br />Bb. FACllITY.NAME III not Inelllullon, ~Ive .Iroel .nd numborl
<br />
<br />77
<br />88. PLACE OF DEATH
<br />~:
<br />
<br />December 24,1929
<br />
<br />
<br />l:J InpoU.nI
<br />
<br />lmlEfI: l:J NUISlng 1-10"",IlTC [lJ Ho.pl"" F.dely
<br />
<br />~
<br />liE
<br />o
<br />;;l
<br />~
<br />~
<br />i
<br />11
<br />I
<br />
<br />l:J EI1I01J~ab.nt
<br />
<br />D OocodOnr. Hom.
<br />
<br />Hospice House
<br />80. OITY OR TOWN OF DEATH (IncIUd. ZIp Codo)
<br />
<br />Omaha 68124
<br />90. RESIDENCE-STATE
<br />
<br />Nebraska
<br />9<1. STflEET AND NUMBER
<br />
<br />112 West 21 st Street
<br />to.. MARIU\L STATUS AT TIME OF DEATH iii Ma"led a Never Momod
<br />
<br />o 000. OO","r(Spedly)
<br />ed. COUNTY OF DEATH
<br />
<br />=
<br /><n
<br />...
<br />
<br />o M.rned. bul separaleu 0 Widowed 0 Divorced 0 Unknown
<br />
<br />
<br />68801
<br />tOb. NAME OF SPOUSE (Arol. Middle, L.el, Sulftx) II wile, gI.e meldenneme.
<br />
<br />
<br />91. ZIP CODE
<br />
<br />9g. INSIDE CITY LIMITS
<br />I1J YES 0 NO
<br />
<br />9b.COUNTV
<br />
<br />Hall
<br />
<br />._".~,......~ ~,,..-
<br />
<br />:r_---:: ,. -.....-.-.-- ',~-", ,. ~""';"'--:"':~~"""""C::; :;".c..._~..J"';;"-;:
<br />
<br />u
<br />.!
<br />{l
<br />
<br />11. FATHER'S-NAME (Fila I, Middle. L..t,
<br />Theodore M Pomero
<br />13. EVER IN U.S. ARMED FORCES? GIVO dalee 01 eOlVlce II yes.
<br />(Ye., no. orun/(.) No
<br />15. METHOD OF DISPOSITION t6.. EMBALMER.SIGNATURE
<br />III Burta' D Don.llon
<br />D Cremotion a Enlombment
<br />D Remo.al 0 Other (SpeOl'yl
<br />
<br />(FI,"I.
<br />
<br />Mlddl., Malden Sumeme,
<br />
<br />Edith Davis
<br />
<br />t4b. RELATIONSHIP TO DECEDENT
<br />
<br />Husband
<br />t6c. DATE (Mo.. Day, Yr. )
<br />
<br />October 15, 2007
<br />$ TATE
<br />
<br />Wesllllwn Memorial Park Cemetery
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Slrnl, ClIy or Town, Slot.1
<br />
<br />A fel Funeral Home, 1123 W. 2nd, Grand Island, Nebreska
<br />CAUSE OF DEATH (See
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />17b. Zip Code
<br />
<br />6B801
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />18. PAI1T I. Enl.r the chain ol...nl.-.dl.e..... InJuri.., or compllcallon...II..1 dlroclly c.u.od!he dO.th. DO NOT onl.r l.nnln.I..ont. .uch a. cardiac ."".\
<br />",.plratory a"e.l. or..nlrlcular IIMlallon without Bhowlng Iha .lIology. DO NOT ABBREVIATE. Enleronty one came on .lIno. Add 'dd/lonal e_ II nece...ry.
<br />
<br />IMMEDIATE CAUSEIFh.'
<br />als...e or olll1dl1On ,nultlng
<br />hdoa"
<br />
<br />(a)
<br />
<br />DUE TO. OR AS A CONSEQUENCE O~:
<br />
<br />IMMEDIATE GAUSE:
<br />ll"1c.~4>h-lic.
<br />
<br />poc..IJ c\if~erl....hedcel C4rCl f1Q,....<1..
<br />
<br />I
<br />I
<br />I ono.llo dealh
<br />I
<br />I Pee.... 1... 00<0
<br />I
<br />I ""selID death
<br />I
<br />I
<br />1
<br />lono.ll. dealh
<br />I
<br />1----
<br />
<br />8Oquenlta'" 1I.lcondltlon_,.
<br />.ny, leading to lhe <oU.. hied
<br />on lhle ..
<br />o ent-:".l!"'P:ef1l't'-"!~!!$L
<br />(dIs.au 0' In~ thellnntet.d
<br />lho .venlo rtsul\lnt In doalh)
<br />lJSr
<br />
<br />(h)
<br />
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />
<br />""Tcr---'-'
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />oneello death
<br />
<br />Id)
<br />
<br />D AccldenlO P.ndn~ In.e.lgollon
<br />D Suldde 0 Could nolbe delennlned
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />D DrIv.r/Op.rator
<br />
<br />D pa..onger
<br />
<br />D Pede.lrien
<br />
<br />o Ol1.r (Sp.ClIyI
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />pi( YES a NO
<br />21C. WAS AN AUTOPSV PERFORMED7
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDlTlONS.CondlUon. conlribUlln~ 10 the dealh bUl nol reGullln~ln \he underlying caUl.lI'ven III PART I.
<br />
<br />15
<br />Ii:
<br />~
<br />f
<br />i
<br />..
<br />1!.
<br />E
<br />8
<br />
<br />20. IF FEMALE:
<br />.lll No' p",gnanl wllhln pa.t year
<br />o Progoanl alllm. 01 d..lh
<br />D Nol pregnant. bul progoonl wllhln 42doyo 01 doalh
<br />D Nol pregnant, but pregtlllnt43 day. 10 t y.erbelore dealh
<br />D Unknown" pregnenlwl,",n Ihe pa.l ye.r
<br />
<br />210. MANNER OF DEATH
<br />)II Nalu",1 0 Homletdo
<br />
<br />DYES I2fNo
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABlE TO
<br />COMPLETE GAUSE OF DEATH?
<br />DYES ONO
<br />
<br />o YES DNa
<br />
<br />
<br />22.. DATE OF INJURV (Me., Day, Vr.)
<br />
<br />22b. TIME OF INJURV 22c. PLACE OF INJURY.AI home. I.rm, 61r6el. 'eclory, olllce bUIlding. con.trucllon .11.. elc. (Sp.cllyl
<br />m
<br />
<br />.
<br />m
<br />
<br />{l 22d.INJUAV AT WORK?
<br />
<br />221. LOGATION OF INJURY. STflEEl & NUMBER. APT. NO.
<br />
<br />CITYIfONN
<br />
<br />SWE
<br />
<br />ZIP CODE
<br />
<br />230. DATE OF DEATH (Mo.. D.y. Yr.)
<br />October 11, 2007
<br />
<br />24a. DATE SIGNED (Mo., Day, Vr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />!"~
<br />'ill
<br />li~
<br />S:i5
<br />.!~
<br />~!i!'
<br />
<br />23b. DAre-SIGNED (Mo..LJ.y, Yr.)
<br />10 .:l3 01
<br />
<br />'23c. TIME CF DEAI'Ii
<br />12:03 p m
<br />
<br />~i~
<br />lli~
<br />811i~~
<br />.z;:l
<br />~~g
<br />8~
<br />
<br />m
<br />
<br />23d. To Ih. bOG' 01 my knowl.dge, dentn occu"od 01 tho limo, dllle and plnco
<br />and due to tho ..u..{.) .I.ted. (Slgn.lure and mle) T
<br />
<br />240. On th. b..I. 01 ...mlna'on ondlorlnve.bgallnn, In my opinion doalh oC!lUlred at
<br />!he time. date ond pia.. and due. 10 the oau..(.) .t.led. (~Ign.lurn and TIll.)"
<br />
<br />p
<br />
<br />
<br />-:ha.......
<br />
<br />280. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />!:JVES aNO
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo.. Dey. Yr.)
<br />
<br />OCT 2 6 2007
<br />
<br />:~...
<br />'l'.:;", ,
<br />. , ';"'. ,,"" J ','" ~:~ {":<',l/':',~',/' ,:' ,,~; ;
<br />This ce#ipes' thisdocl1~1irl~~<iq~r~trl1e copy of an original record on file with Vital Statistics, Douglas County
<br />Heal!hDp~t,:O~aha':N)bl'~~.:Certifi~d copies must have a raised seal in the area to the left. Reproductions
<br />of thlsgr~~f.~r:trfj~a~~,~e npt legal copIes.
<br />
<br />Date Issued:
<br />
<br />"OCT26 ZOOl
<br />'"0 ""i" '~, ~ "\
<br />
<br />Registrar:
<br />
<br />AJlS-. -;i'-'-g ~
<br />
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