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<br />STATE OF NEBRASKA ......... ... .
<br />
<br />WHEN THIS COpy CARRIES THE R~/SED SEAL OF THE NEBRASKA HEALTHAND~'!/~.~~E.RVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BEA TRUE COpy OF THE ORIGINAL R5fJPR.UPJi1~~!"':H
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA71ST~/~~Rn.!~
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. .#... ..J. ,--._.:F&.. ~.?.A.;:..J}.. ... -CC.W". -~ . .;...-C;..j...~~~.'.-=.. ~.i=.
<br />
<br />DAtE OF ISSUANCE )VTE~;h~~1\
<br />DEe 1 3 2005 Assl5TANi$iliehiGIS1:R~M
<br />LINCOLN, NEBRASKA 20080866 9 HE~LT~t;~K~~~~:f .
<br />
<br />
<br />..... , '~-'"..~,
<br />- ".":'.2:::'=:'. :-..~-:,:~~::~':=::'. ',=-
<br />-- "~-' '-::-..~ ':"".
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<br />
<br />.
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<br />1.DECEDENT'S-NAME (Flrsl,
<br />Norma
<br />
<br />STATE OF NEBRASKA-DEPARTMENTOF HEALTH AND HUMAN SERVICES FINA NCE AND SUPPORT. 5 1.__ 36..1.._. 8 ..
<br />CERTIFICATE OF DEATH '..
<br />
<br />Middle,
<br />Ann
<br />
<br />Last,
<br />Lambert
<br />
<br />Sulllx)
<br />
<br />2.SEX
<br />Female
<br />
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 30, 2005
<br />
<br />"
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Boelus, Nebraska
<br />
<br />5e. AGE-Le't Blrlhday 5b. UNDER 1 YEAR
<br />(Yrs) 72 MOS. DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />~
<br />
<br />July 19, 1933
<br />
<br />8a. PLACE OF DEATH
<br />
<br />FACILITY.NAME (II not In"ilullon, give slr.at .nd numb.r)
<br />
<br />J:l.Q.SEJIAJ.; 0 Inp.llenl Q!!:tiJ: XI Nur'l~g Hom,/LTC 0 Ho'pic. Faolllly
<br />
<br />Beverly Healthcare Park Place
<br />
<br />o ER/Outpall.nl 0 Decedenl's Home
<br />
<br />o [0\ OOlher(SpocifyL_.._.__
<br />8c. CITY OR TOWN OF DEATH (Includ. Zip Cod.) ---T 8d. COUNTY OF DEATH
<br />Grand Island 68803 ~ Hall
<br />90:RESIDENCE:$WE- ---T9b COUNTv 9c. CITY OR TOWN ----
<br />Nebraska -------L Hall Grand Island
<br />9d.STREETANDNUMB~ 9. APT. NO 19t.ZIPC~--~iNSIDECITYLlMITS
<br />110 West 18th St. 68801 ~ Xl YES 0 NO
<br />;0,. 'AA'''' """'" ""' 0> "~~ "",-,. 0 ,-, "",.. r. """ ;~,. """. =)~" .,". "" ..,~";;;;-
<br />
<br />o M."lod, bUIS.parOlod 0 WldowOd ODlvorcod 0 Unknown Neil Lambert
<br />
<br />11-,-~'NAME-~ -M~- ~ ------s;;;I!;)I;2~MOTHER'S-NAME ~-- Mlddl., -~n Surname)
<br />_____.....Augu~._____. Bremer_._l__f. nes Hansen
<br />13. EVER IN U.S. ARMED FORCES? Glvo dale, 01 sorvlce II y.s. 14..INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />
<br />(Y.':_no, or unk~~
<br />15. M~THOD OF DISPOSITION
<br />~Burlal 0 Donallon
<br />o Cromolion 0 Enlombmenl
<br />
<br />
<br />Husband
<br />16c. DATE (Mo., Day, Yr.)
<br />
<br />Dec:'.embe~ 2005_
<br />STATE
<br />
<br />o Removal 0 Olhor (Specify)
<br />
<br />Westlawn Memorial Park Cemetery
<br />
<br />Nebraska
<br />
<br />(Slroal, CllyorTown, Slala)
<br />
<br />..._'.'._.._~-.~
<br />
<br />PART I. Enl.r Ihe chain of evenlsndlG8o,o" inJurlos, or complicallononlhal directly cau.ed Ih. doalh. DO NOT enl.r larmlnol ov.nls such .s cardiac a".sl,
<br />ro.plratory a"esl, or vantricul.r librlllation wilhoUI ,howlng th. .tlology. DO NOT ABBREVIATE. Enlar only on. cou,. on . line. Add addlllonellinao If nec.ssory.
<br />
<br />IMMEDIAT~ CAUSE: Q on.allO dealh
<br />
<br />
<br />IMMEDIATE CAUSE (Final ~r,",~ ~~Cl:vuJ.-..,....,^ ~\\Ja...tz .__~
<br />dl.....orcondltlonr..ultlng DUE TO, OR AS A CONSEi:IlJENC'EOF~ I ons.1 to doolh
<br />In dealh)
<br />
<br />S.qu.nll'lIy 11.1 condition., If (b) ~ () b. i'\
<br />.ny, le.ding 10 the c.u..II"ed DUE TO, OR AS AC~UENCE OF:
<br />on line 8.
<br />Enler Ihe UNDERLYING CAUSE
<br />(dl..... or Inlury lhallnlli.l.d (c)
<br />th.evenl. r.,ulllng In deolh) DUE TO, OR ASA CONSEQUENCE6~' .------.-
<br />LAST
<br />
<br />C-
<br />
<br />: ,,11 _
<br />--------'--~lY~
<br />r onsello dealh
<br />I
<br />I
<br />I
<br />
<br />on,ol 10 d.alh
<br />
<br />(d)
<br />
<br />R SIGNIFICANT CONDITIONS-Condlllono eonlrlbullng 10 Iho dO.lh bUI nol r.sultlng in Ihe undorlying cause given In PART L
<br />
<br />"-""._'.'~-".,.-.",,-,_-,._._~
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<br />20. IF FEMA[E: 21b.IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />lOrNol pragnonl within p.sl yoo, ODrlver/Op.ralor
<br />
<br />o Pregnanl alllm. 01 de.lh 0 AccldenlO Pending Invesligallon 0 Passen9.r
<br />
<br />o NOI pr.gnonl, bul prognent wllhln 42 days of de.lh 0 Sulcldo 0 Could nol be d.t.rmlned 0 Pade'trlan 21d. WERE AUTOPSY FINOINGS AVAILABLE TO
<br />o Nol prognonl, bul pregnanl43 doys 10 1 yeer b.loro de.lh 0 Olher (Spoclfy) COMPLETE CAUSE OF DEATH?
<br />o Unknown II prognonlwilhln the p..I yeer ___ 0 YES iU'l;0
<br />
<br />_=E OF INJURY (Mo, D'~ME OF INJUR:LPLACE OF INJURY-~I homa, form, slreel, ~.CIOrY, offlco bUilding, oO-;;SIruellon '''a, ele (Spoclfy) -~
<br />
<br />
<br />22d.INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />lIWI* ~p~V'Jl- ~
<br />
<br />
<br />-.w~.ro-
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CON~;rED?
<br />
<br />DYES 'O""N0
<br />
<br />LJ YES
<br />
<br />~O
<br />
<br />o YES ~
<br />
<br />221. LOCATION OF fNJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYffOWN
<br />
<br />~"-'-._,-,--
<br />
<br />STArE
<br />
<br />-ZIP CODE
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<br />23.. DATE OF DEATH (Mo" Doy, Yr.)
<br />November 30,2005
<br />
<br />24a. DATE SIGNED (Mo" Doy, Yr.)
<br />
<br />'-".'--"-'~~'
<br />
<br />m
<br />
<br />...~~
<br />J:lUz
<br />i-15
<br />dh
<br />g~[::15
<br />uwz
<br />.8z;i!
<br />~~fj
<br />o~
<br />Uo
<br />
<br />24b. TIME OF DEATH
<br />
<br />26~"tEJ~rg~(~OlD:Y2'd 0 50 . 23c. TIMgO! ~E~~
<br />
<br />m
<br />
<br />24C. PRONOUNCED DEAO (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
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<br />24e. On lhe basis or examlnatlon and/or investigation, In my opinion dealh occurred al
<br />Ihe lim., date ond ploce ond duolo Ih. causers) .1.lad. (Signalure and Tille) '"
<br />
<br />25. DID TOBACCO U E 2 o. HAS ORGAN OR TiSSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />
<br />~ 0 NO 0 PROBABLY 0 UNKNOWN 0 YES ~ NOI Appllc.bl~_il26. I'~O 0 YES ib1ro
<br />---V:-NAME, TITLE AND ADDRESS Oi'CERTlFiER (PHYSICIAN, CORONER'S PHYSiCIAN OR COUNTY ATTORNEY) (Type Or Prlnri--
<br />Ryan Crouch D.O. 800 . Alpha Ave.." Grand Island, NE. 68803
<br />
<br />28a. REGISTRAR'S SiGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo" D.y, Yr.)
<br />
<br />DEe ~ 9 2005
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