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<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 />
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