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<br />
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HYMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASK-dD'5Pl4~~pF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR .'!ffA. ~~~,~ /} ) J.
<br />
<br />. . \r,(lJt;~
<br />DATE OF ISSUANCE...,...~ .'..... . .._' . '., ~ _. -t-/
<br />2 0 0 8 0 7 4 8 9" f!1lt!Lf.'(!j.CaDPEJ1./",.,'_"~ I,
<br />JUL 2 8 2008'fs:JS:FA~" TEf{EflJ$~.4JB. "
<br />dfeARTM T.... :4I!rA!"Bi ~ -
<br />UNCOLN, NEBRASKA ~~ "':"<'", ,'it ;:
<br />
<br />STATEOFNEBRASKA-DEPARTMENTOFHEALTHANDHUMA;~~.C "J:~~~r .' -~.~,.,., ~.""..." \."
<br />CE T E 4 <" ,.':'W"00.~.' ~."z,"C.-.
<br />1. DECEDENl'S-NAME (FI...t. Middle, Loot. Sumo) 2.$Ell .' tt &JUU}F II "1l~,-j'J
<br />Karen Jean Bor mann Female li.-\ \ l II · - .
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTIl
<br />
<br />
<br />6.0. AGE-Lool Blrll1dey lb. UNDER 1 YEAR 6<:. UNDER 1 OAY
<br />
<br />(Y",.)
<br />
<br />MOS. DAYS
<br />
<br />1l0URS III1NS.
<br />
<br />Ord, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />57
<br />
<br />August 11, 1950
<br />
<br />8a. PLACE OF DEATIl
<br />
<br />~ 0 Inpall.nl
<br />
<br />o ERlOulpellenl
<br />[J'lltD." ~ ~--.-
<br />
<br />o Ilo.plc. Facility
<br />
<br />505-72-3950
<br />
<br />8b. FACILITY-IIIAME (If nolln.lltulfon, give .Ireelend number)
<br />
<br />~o Nu...lng 1l0motll.TC
<br />
<br />iii DeCedenl'. Ilomo
<br />-'~"d-~"
<br />
<br />'~m-we;;ITit~ ~j,;e~~~~'
<br />
<br />...I
<br />~
<br />W
<br />Z
<br />::;l
<br />IL
<br />~
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<br />.....
<br />
<br />80. crrv OR TOWN OF DEATIl (Include Zip Code)
<br />Grand Island 68803
<br />
<br />8d. COUNTY OF DEATIl
<br />Hall
<br />
<br />Be. RESIDENCE-STATE Bb. COUNTY
<br />
<br />
<br />68803
<br />
<br />Nebraska
<br />Bd; STREET AND NUMBER
<br />
<br />Hall
<br />
<br />If. ZIP CODE
<br />
<br />9g. INSIDE CITY LIMITS
<br />ID Y.. 0 No
<br />
<br />1912 West 11th Avenue
<br />
<br />10e. MARITAL STATUS AT TIME OF DEATIl iii Man1.d 0 Never Man1ed 10b. NAME OF SPOUSE (FI"'I. Middle, La.t. Sufflo) "wfle, glv. m.lden neme.
<br />
<br />
<br />o Men1ed, bul oepereled 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Louis
<br />
<br />Pesek
<br />
<br />
<br />STATE
<br />
<br />11. FATIlER'S-NAME (FI"'t. Mlddl., Lnl, sumo)
<br />
<br />Middle, Malden Surneme)
<br />
<br />13. EVER IN U.S. ARMED FORCES? Glv. d.te. ohervlcellY...
<br />
<br />(Yes, No. or Unk.) No
<br />
<br />1&. METIlOD OF DISPOSITION
<br />liiJBul'I.I1 OD....Uon
<br />
<br />DCfWlMtlon OEntombment
<br />o R*,,"oval Oothtr'(Bpeclfy)
<br />
<br />14b. RELATlONSIlIP TO DECEDENT
<br />
<br />Husband
<br />180. DATE (MD., Day, Yr.)
<br />Jul 5,2008
<br />
<br />18b. LICENSE NO.
<br />
<br />/071
<br />
<br />CITYITOWN
<br />
<br />Grand Island Cemetery
<br />
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (SI..el, CI.y or Town, Slele'
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />17b. ZIp Code
<br />68801
<br />
<br />CAUSE OF DEATH See instructions and exam les
<br />
<br />,,- PA"T I. Entlllr tt1t1 eh.", of Olfitnk - ~I"..es, InJuries. or eompllcOItlon.- that dlr&ctly t:.u.w.d the death_ DO NOT enter telltliftil:1 .-v.nt.. .u~h a. cardiac .~,""...
<br />reSPiratory arrest, or vCln~(lcYlat fibrillation wlthQut Showing the etiOlogy, DO NOT ABBR~VIATE. Entlltr only one C.L1'. on a linll. Add .<fdlllon.alllnIll'B If neclI!I,sary.
<br />
<br />APPROXIMATE INTERVAL
<br />I oneello d..lh
<br />I
<br />I unknown
<br />
<br />IMMl'DIATE CAUSE:
<br />
<br />IMIIIEDlATE CAUSE (Fine'
<br />dleeesoorcondlllonreeulllng .) cardiopulmonary arrest
<br />In d..th)
<br />
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />I
<br />I 7 months
<br />
<br />Soqu.nti.lly 11.1 condlllon.. If b)
<br />.ny, leedlng 10 Ih. c.u.. Ii.led bra i n can c e r
<br />
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on..t to death
<br />I
<br />I
<br />
<br />Enler Ihe UNDERLYING CAUSE 0)
<br />(dl..... or Injury th.llnllleled
<br />Ihe evente re.ulllng In deelh) DUE TO. OR AS A CONSEQUENCE OF:
<br />LAST
<br />
<br />On.et to death
<br />I
<br />I
<br />
<br />d)
<br />
<br />18. PART II. OTIlER SIGNIFICANT CONDITIONS.condltlon. conlrlbullng 10 the deelh bUI nol reoulUng In Iho und.rlylng ceu.. given In PART I.
<br />
<br />19. WAS I\1EDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />I) YES ..fB-No
<br />
<br />It:
<br />W
<br />u::
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<br />w
<br />u
<br />~
<br />~
<br />Q.
<br />8
<br />u
<br />Ql
<br />lJ:I
<br />{:.
<br />
<br />20. IF FEMALE:
<br />IlU NOI pregnenl within p..1 yeer
<br />o Pregnenl et tlm. of dealh
<br />o NOI pregnent, bUI pregn.nl within 42 daya 0' dOeth
<br />o Not pregnant, but pregnant 43 days to 1 )'ear before death
<br />OUnknown If pregnanl within the pesl yoar
<br />
<br />21.. MANNER OF DEATIl
<br />X;:J Nelurel 0 Ilomlclde
<br />o Acold.nt 0 Pondlng Invoollgallon
<br />o Suicide 0 Could nol be determln'd
<br />
<br />21b.IF TRANSPORTATION INJURY
<br />o Driver/Operalor
<br />o P....nger
<br />o Pedaolrlan
<br />o Other (Specify)
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />o YES tia NO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATIl?
<br />
<br />DYES 0lI NO
<br />
<br />22d. INJURY AT WORK?
<br />DYES ONO
<br />
<br />
<br />220. DATE OF INJURY (Mo., Dey, Yr.)
<br />
<br />22b. TIME OF INJURY 220. PLACE OF INJURY-A. homo. Iill1II, .I....t. faclory. office building, con.trucllon .lIe, elc. (Sp,clfy)
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP COOE
<br />
<br />z
<br />.:=!
<br />it-
<br />l:I.l1...l
<br />E ""z
<br />8,,0
<br />.z'g
<br />~~
<br />
<br />23e. DATE OF DEATIl (MD., Dey, Yr.)
<br />
<br />:g:~~
<br />iiii!
<br />1l~1:>
<br />a:;;<2!
<br />~ ~~ 0
<br />uWz
<br />21 Z::l
<br />o~o
<br />to- o~
<br />00
<br />
<br />
<br />240. DATE SIGNED (MOo, Day, Yr.)
<br />
<br />24b. TIME OF DEA TIl
<br />
<br />Jul
<br />
<br />3 2008
<br />
<br />1:20
<br />
<br />m
<br />
<br />23b. DATE SIGNED (Mo., Dey, Yr.)
<br />
<br />230. TIME OF DEATH
<br />
<br />240. PRONOUNCED DEAD (Mo., Dey, Yr.) 24<1. TIME PRONOUNCED DEAD
<br />
<br />Jul
<br />
<br />1, 2008
<br />
<br />2:25
<br />
<br />m
<br />
<br />m
<br />
<br />23d. To the be.t of my knowledge, death occurred at the firM, dale and place
<br />and due'o the ceu..(.) oleled. (Signature .nd Tille)
<br />
<br />248. On the basis Of examination Indlor Iny..lIgatlon. In my opinion d,.th occurred
<br />at the time, date and place 8nd due to the c.uM(.) .t.tect. (Signature Ind Title)
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO TilE DEATIl?
<br />o YES KI NO 0 PROBABLY 0 UNKNOWN
<br />
<br />260. liAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES IJI NO
<br />
<br />ONO
<br />
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PIlYSICIAN, CORONER'S PIlYSICIAN OR COUNTY ATTORNEY) (Typ. or Prfnt)
<br />
<br />Mark J. Youn
<br />28.. REGISTRAR'S SIGNATURE
<br />
<br />all
<br />
<br />A
<br />
<br />
<br />p
<br />
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