|
<br />
<br />STATE OF NEBRASKA . . ,
<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. RECORDDNFILEWITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAPS'nt;StECttclii;C-WHICHIS
<br />
<br />:~:~;S:::RY FOR Y1TAL RECORDS j~. :~.;,; ";t,t;;;t.;:
<br />NOV 2 9 2006 2 0 0 80 6 9 2 9 ::~$~~!~~~t::
<br />LINCOLN, NEBRASKA HEAL1l:J ~~i~~~~tlsEFfi1ICES
<br />
<br />_.,,-
<br />
<br />STATE OF NEBRAsKA - DEPARTMENT OF HEALTH AND HUM. .A.N S... ERVICES FINANCE AND SUP. paR}.. 6
<br />~ CERTIFICATE OF I:)I:~TH .__ u~ 321.60
<br />
<br />1. DECEDENT'S.NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo" Dey, Yr.)
<br />Beverly Sue Clark Female November 7, 2006
<br />
<br />4. CITY AND STATE OR TER~ITORY, OR FOREIGN COUNTRY OF BIRTH l~a. AGE-Laal Birthday 5b. UNDER 1 YEAR 50. UNDER 1 DAY 6. ~ATE~F BIRTH (Mo" Day, Yr.)
<br />(Yrs) MOS. DAYS HOURS MINS.
<br />Crawford, Nebraska 61 July 21, 1945
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />506-68-0454
<br />
<br />8a. PLACE OF DEATH
<br />Ho.sElIAl.:
<br />
<br />o Inpatlant
<br />
<br />QlliEB; Cl Nursing Home/LTC 0 Hosploe Facility
<br />
<br />8b, FACILITY-NAME (If not In,tltution, glva streel and number)
<br />
<br />o ERIOutpatlent
<br />
<br />~ Dl;!cedent's Home
<br />
<br />Home:
<br />
<br />509 E. 11th
<br />
<br />00Cl\
<br />
<br />o Other (Speciry)
<br />
<br />ge. RESIDENCE.STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />
<br />68883
<br />~'~ 9bCOUN;all
<br />
<br />8d. COUNTY OF DEATH
<br />Hall
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Wood River
<br />
<br />509 E. 11th
<br />
<br />
<br />91. ZIP CODE
<br />68883
<br />
<br />9g. INSIDE CITY LIMITS
<br />ij YES 0 NO
<br />
<br />lOa. MARITAL STATUS ATTIME OF DEATH C!Marrled 0 Never Married lOb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wile, give maiden name.
<br />OMarried,bulseparaled OWldowe~ ODivorced OUnknown Garner B. Clark
<br />
<br />11. FATHER'S.NAME IFirsl,
<br />Lloyd
<br />
<br />Middle,
<br />
<br />Last,
<br />Smith
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S.NAME (Flrsl,
<br />Myrtle
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />Siekert
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dales of serviea if yes. 14a.INFDRMANT-NAME
<br />(Yes, no, orunk.) No Garner B. Clark
<br />16a. EMBALMER.SIGNATURE U.. ..,--\ leb. LICE. NS. E. ..N_.O.
<br />o Burial o Donallon Not Embalmed ~
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />
<br />~Cromatlon 0 Entombmenl
<br />U Removal 0 Other (Specify)
<br />
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY fTOWN
<br />
<br />16C. DATE (Mo" Day, Yr. )
<br />
<br />}iovember 7, 2006
<br />STATE
<br />
<br />Westlawn Memorial Park Crematory
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreel, City orTown, State)
<br />Apfel Funeral Home, 1123 West Second,
<br />
<br />Grand Island, NE
<br />
<br />PART I. Enter the ~.'LI!l\l~:-dlsea'e., Injurle', or eomplications--tMt directly cau.e~ Ihe death. DO NOT enler lermlnal evenls such as car~lac arrest,
<br />...__:,l"IllJalOl.lL.3r",.t,,,OLV.!In!!}c.ul~l fibrUlallonwUhou!..hcwlng Ihe etiology. DO NOT ~BBREVIATE. Enter only one cause on . line. Add a~dlllonal Une. if necess.ry.
<br />--- -
<br />IMMEDIATE CAUSE:
<br />
<br />
<br />17b. Zip Codo
<br />68801
<br />
<br />onsetlo death
<br />
<br />IMMEDIATE GAUSE (Flnel
<br />disease or con~ltlon ,".ultlng
<br />Inde~th)
<br />
<br />~__~ll V <'>r YCl-\; kv--u
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />rv ed'VJ
<br />
<br />onset 10 dealh
<br />
<br />Sequentially list conditions, It
<br />any, leadIng to the cause listed
<br />on line a.
<br />Enler the UNDERLYING CAUSE
<br />(dl..... or Injury that Initleled
<br />the .v.nl. r..ulllng In dealh)
<br />LASr
<br />
<br />(b)
<br />
<br />1'0 e-t' ()J)'t; OvtG D
<br />
<br />o V'(AfrP Cln
<br />
<br />l'ttn LeJz.
<br />
<br />\k?t;II1-6
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />(c)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsel to ~eeth
<br />
<br />(d)
<br />
<br />o AccldenlO Pending Investigation
<br />
<br />21b. IFTRANSPORTATION INJURY
<br />o Drlver/Operetor
<br />
<br />o Passongor
<br />
<br />U Pe~estri.n
<br />
<br />19. WAS'MEDIC AMINER
<br />
<br />OR CORONE~NTACTED?
<br />
<br />DYES i'liNO
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />-
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS.Condition. contributing to the death bul nol resulting In the underlying cause given In PART L
<br />
<br />20. IF FEMALE:
<br />j!j Not pregnant within ps.1 yeer
<br />o Pregn.nlal limo 01 death
<br />o Not pregnanl, but pregnanl within 42 ~ey. 01 ~e.th
<br />o Not pregnant, but pregnant 43 ~ays to I year belor. deeth
<br />o Unknown II pregnant within the past year
<br />
<br />21.. MANN~R OF DEATH
<br />jil,Natural 0 Homlcl~e
<br />
<br />U YES
<br />
<br />.N~
<br />
<br />o Suicide 0 Coul~ not be ~etermlned
<br />
<br />21~. WERE AUTOPSY FIN
<br />
<br />AVAILABLE TO
<br />
<br />22.. DAT~ OF INJURY (Mo., Day, Yr.)
<br />
<br />22b. TIME OF INJURY
<br />
<br />COMPLETE CAUSE OIirlilillTH?
<br />..
<br />DYES 0 i!O
<br />__ _.._,""".,_~ - M'.'"'" , ,':
<br />22t. PLACE OF INJUftY.AI home, farm, street, f.Clory, oifice buil~ing, construclion silO, otc. (SpeclfyM
<br />
<br />o Olher (Specify)
<br />
<br />DYES 0 NO
<br />
<br />
<br />m
<br />
<br />221. LOCATION OF INJURY. STREET & NUMB~R, APT NO.
<br />
<br />CITY/TOWN
<br />
<br />SlATE
<br />
<br />ZIPCQuE
<br />
<br />23a. PAT~ Of D~ATH (Mo., Day, Yr.)
<br />
<br />~L..I
<br />
<br />23b. DATE SIGNED (M ., Day, Yr.)
<br />n
<br />
<br />24a. DATE SIGNED (Mo" Pay, Yr.)
<br />
<br />24b.TIME OF DEATH
<br />
<br />N\.. D
<br />
<br />...:;:1;;
<br />..,,:; z
<br />iyjl!:
<br />:ii~~
<br />~... <(!:;
<br />..~z
<br />il:zO
<br />.!l~i5
<br />~a:U
<br />815
<br />
<br />m
<br />
<br />24C. PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examInation and/or Investigation, in my opinion death occurred at
<br />Ihe limo, dete and place and due to tho causers) S1ale~. (Signature and Title) "
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />(J YES ~.N.~. O~ROBABLY 0 UNKNOWN ____[] YES )Q NO . ..~_
<br />27. NAME, TITLE AND ADDR~SS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Anita Deshpande M.D. 2116 . Faidley. Av. Grand
<br />
<br />28b. WAS CONSENT GRANTED?
<br />
<br />Not~~plicable If 26a I. NO LJ YES 0 NO
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />Island, NE.
<br />
<br />68803
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />NOV 1 S 2006
<br />
|