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<br />.. <br />~ <br /> <br />. <br /> <br />STATE OF NEBRASKA <br /> <br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF H.E... AL TH,~, ...'J;}"tlJJMAN SERVICES, IT CERTIFIES <br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB~ 'JIA'R'f'Nfi.riT OF HEAL TH AND <br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITOR'( ~~V~.... . ~~, ~i i.., <br /> <br />DATE OF ISSUANCE ~~;;~ <br />,;~ MANLEY ~efJOpeR '.' · ,.' <br />OCT 1 7 2008 20080,90 56 ....'.: :zi~..lSfIIlrv,r-.sTiTfi.REG~5i~AF <br />LINCOLN, NEBRASKA ':.:, '~A~~~~L ;~~ <br /> <br />"I~ 0'-' f "'::,:,,~.,.~ .....J <br />~'-l ..f I.~~;;:- .....'.'?-......) ..,-::' <br />. !~":r;':-,~~!>~y,: '.:,,;\ -':.:;' <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES'FINt~~IiJlrlll?~Ufi'~~0-6' <br />CERTIFICATE OF DEATH ~,- , ., < , ,.,J.:) 0 <br /> <br />r:.) <br />,,co <br /> <br /> <br />1. DECEDENT'S-NAME (First, <br />Scott <br /> <br />Middlo, <br />Paul <br /> <br />Lasl, <br />Beaudette <br /> <br />Sufll.) <br /> <br />2.SEX <br />Male <br /> <br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH <br /> <br />Sa, AGE-Lasl Birthday <br />IYrs,) <br />52 <br /> <br />5b. UNDER I YEAR <br />MOS, DAYS <br /> <br />5c, UNDER I DAY <br />HOURS MINS, <br /> <br />Bloomfield. Nebraska <br /> <br />7, SOCIAL SECURITY NUMBER <br />507-80-1199 <br /> <br />eo. PLACE OF DEATH <br />liQSflIAl., Illnpationl <br /> <br />o ER/Outpallenl <br /> <br />St. Francis Medical Center <br /> <br />[J0CJ0\ <br /> <br />Be, CITY OR TOWN OF DEATH (Includo Zip Code) <br />Grand Island <br />9a. RESIDENCE.STATE <br />Nebraska <br />ed, STREET AND NUMBER <br />1719 S. Harrison St. <br /> <br />68803 <br /> <br />ed. COUNTY OF DEATH <br />Hall <br /> <br />9b, COUNTY <br /> <br /> <br />Hall <br /> <br /> <br />3. DATE OF DEATH (Mo" Day, Yr,) <br />October 4. 2008 <br /> <br />6, DATE OF BIRTH (Mo" Day, Yr.) <br /> <br />February 8. 1956 <br /> <br />QIJ:IEB, [J Nurslne Hom./LTC 0 Hospica Facilily <br /> <br />[J Decodent's Home <br /> <br />[J Oth.r ISp.clly) <br /> <br />91, ZIP CODE <br /> <br />ego INSIDE CITY LIMITS <br />Xl YES 0 NO <br /> <br />o Married, but..parated [J Widowed [J Divorcod [J Unknown Cindy Berrick <br /> <br />lOa, MARITAL STATUS AT TIME OF DEATH OlMarrled [J Nav.r Marriod lab. NAME OF SPOUSE (Fir"" Middl., L.st, Sulfix) II wll., glv. m.idan nama. <br /> <br />68803 <br /> <br />PART I. Enter the enaln 01 evp.nl~~-dlseases, injurieS, Or complicalionsntha( direclly caused the dealtl. DO NOT enter terminal ElVents such as cardiac arresl, <br /> <br /> <br />~'-'''~'''""-:::~::TII'-::~'"=":;::^-;'Z~':"~.''"-:"A.n ali~dd addi;a~""."'",_'" 'q'7o~. ~ 10/4 a> <br /> <br />IMMEDIATE CAUSE (Final I V 9 V Wi j}!~ " v)I)It(l( L.I2Ll L t--4- <br />dl.....oreondlUon ..sulUng DUETO. OR AS A CON~QUENCE OF, - , ;;'I~. <br />indoalh) _ ' <br />, <br />, <br />, ons.llo d..th <br />, <br />, <br /> <br />11, FATHER'S-NAME (First, <br />Vonnie <br /> <br />Middl., <br /> <br />LaSI, Sullix) <br /> <br />Beaudette <br /> <br />12, MOTHER'S-NAME (First, <br />Donna. <br /> <br />15, METHOD OF DISPOSiTION <br />l:lBurial [J Donallon <br /> <br /> <br />13, EVER IN U.S. ARMED FORCES? Givo date, olservic. il y.s. 14a.INFORMANT-NAME <br />No <br /> <br />o Cr.m.Uon 0 Enlom~menl <br /> <br />o Romov.1 [J Other (Spocifyl <br /> <br />Grand Island Cemetery. <br /> <br />Grand Island, <br /> <br />17.. FUNERAL HOME NAME AND MAILING ADDRESS ISlr..1, City orTown, St. I.) <br />Apfel Funeral Home. 1123 West Second, <br /> <br />Sequenti.lly list condlllons, If <br />.ny, leading to the cause IIst.d <br />on linea. <br />Enter the UNDERLYING CAUSE <br />(dl..... Or Injury th.tlnlUolod <br />the evenla ...u~lng In death) <br />LAST <br /> <br />Ib) <br /> <br />DUE TO, OR AS A CONSEQUENCE OF: <br /> <br />(c) <br /> <br />DUE TO, OR AS A CONSEQUENCE OF: <br /> <br />(d) <br /> <br /> <br />IS. PART II. OTHER S;:JT CO=~7;;::::; b~r r. <br />ff____-.____ <br /> <br />20, IF FEMALE; 21a. Mi).NNER OF DEATH <br />[J 1'101 pregnanl within pa'l y.ar ,.i:l.Na'ural [J Homicld. <br />[J pr.gnantal 'im. of de.lh [J Accid.nl[J P.ndinglnv.sUg.tion <br />[J Not prognanl, bul pregnanl wilhin 42 days 01 d.alh [J Suicide [J Could nol bo dewmined <br />[J 1'101 pregnanl, bUI pr.gnanl43 days 10 I y.ar belor. d.sth <br />[J Unknown If pregnant within Ihe past yo.r <br /> <br />21b.IFTRANSPORTATION INJURY <br />[J Driver/Operelor <br /> <br />[J Pass.ng.r <br /> <br />[J Pedestrl.n <br /> <br />[J Other ISp.cily) <br /> <br />22d.INJURY AT WORK? <br /> <br /> <br />22.. DATE OF iNJURY (Mo., Day, Yr.) <br /> <br />Middle, <br /> <br />Maiden Surname) <br />Scott <br /> <br />14b. RELATIONSHIP TO DECEDENT <br />Wife <br /> <br />I 6c. DATE IMo., Day, Yr.) <br />October ~. 2008 <br /> <br />STATE <br /> <br />Nebraska <br /> <br />I OMelia dealh <br /> <br />19. WAS MEDICAL EXAMINER <br />OR CORONER CONTACTED? <br /> <br />[J YES (i('NO <br /> <br />21 c, WAS AN AUTOPSY PERFORMED? <br /> <br />[J YES Iil"NO <br /> <br />21d. WERE AUTOPSY FINDIN"S AVAILABLE TO <br />COMPLETE CAUSE OF DEATH? <br />[J YES [J NO <br /> <br />22b. TIME OF INJURY 22c. PLACE OF INJURY.At homo, f.rm, slreol, laclory, olllce building, con'lructlon .11.,. .tc, (Sp.clry) <br />m <br /> <br />[J YES 0 NO <br /> <br />221, LOCATION OF INJURY - STREET & NUMBER, APT. NO. <br /> <br />CITYIfOWN <br /> <br />23., DATE OF DEATH IMo., Day, Yr.) <br />I 0 j ~-' cg <br /> <br />Z;>- <br />:>oS "' <br />..~~ <br />h~::; <br />fn~ <br />llz;1 <br />~~ts <br />o~ <br />Uo <br /> <br />24., DATE SIGNED (Mo., Day, Yr.1 <br /> <br />23c. TIME OF DEATH <br />u:S~-Am <br /> <br />SWE <br /> <br />ZiP CODE <br /> <br />24b, TIME OF DEATH <br /> <br />24c, PRONOUNCED DEAD (Mo., D.y, Yr.) 24d. TIME PRONOUNCED DEAD <br />m <br /> <br />m <br /> <br />240. On the basis 01 examination and/or inv9sUgation, In my opinion death oocurted at <br />1he Um., dat. and plac. and dU.lo th. cau.e(,) sl.ted, (Signalur. and Tille) T <br /> <br />~ <br /> <br />25, DID TOBACCO USECONTRIBUTETOTHE DEA ? 26.. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br /> <br />f)lYES [J NO [J PROBABLY UNKNOWN [J YES ~O ...:ft <br />'-2~E, T1TLEAND ADDRESS OF CERTIFiER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTYATTORNEYj' IType ci'r-Prlnl) <br />M. Sitki Copur M.D. 2116 West aidley Ave.. Grand <br /> <br />2Bo, REGISTRAR'S SIGNATURE <br /> <br /> <br />26~, WAS CONSENT GRANTED? <br /> <br />1'101 Applicabl. il26a i. NO [J YES <br /> <br />NO <br /> <br />Island. NE <br /> <br />68803 <br /> <br />26b. DATE FILED BY REGISTRAR IMo., Day, Yr,) <br /> <br />OCT 1 4 2008 <br />