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<br />STATE OF NEBRASKA
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<br />WHENTHIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OFHEALTt:t.:.i'ltUMAN SER,VICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB~, Q 'A~fNT OF HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORy}Q1t '<~~~::..' ff!l:~ ~ ii"
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<br />DATE OF ISSUANCE ;:"~,.,^'~
<br />.' kSTANLEY~Ca(J}I?&lJ,.. " ;#
<br />SEP 2 4: 2008 2 0 0 8 0 9 4 8 6 ;,. k":P.5SI~"F- Sf!. t"i 'ii~G{~~*,'RA, R
<br />:- ~~PAf01E!:JTjt)f fi,gAL T.I-tArvP
<br />LINCOLN, NEBRASKA .' :IJOMAN SER:VI(2ES :' ,:. ;-
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<br /> STATE OF NEBRASKA - ~~~7~MENT OF HEA~~T~D HUMAN " l.a, -- 564
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<br /> CER :4TE OFDE ' 'i ';- ....... , ~
<br /> 1. DECEDENT'$-NAME (F''''t, Middle, Lao~ $1IflI.) a,SEX ~t,' I ':f, ~1't OI'1l_EA.UlTlllo"Day,Yr.)
<br /> ... ~" .." .~ '~ ~ '~,' -oI:::-...-'~
<br /> Onamae Patti Wad del Female ., - September 10, 2008
<br /> ) .. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH So, AGE-Laol Birthday 5b. ONDER 1 YEAR ' I;c, UNDER 1 DAY 6. DATE OF BIRTH (11I0" Dey, Yr.),
<br /> (Y",.) 1110S'1 DAYS HOURS I IIIINS.
<br /> HOldrege, Nebraska 59 March 17, 1949
<br /> 7. SOCIAL SECURITY NUMBER 8<<. PLACE OF DEATH
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<br /> \:a:: 508-66-0480 ~ IXIlnpaUanl ~o Nu",lng HomelL TC D Hooplce Facility
<br /> ~ ab, FACILITY.NAME (If notlnolltutlon, glva ot",atond numbar) D ERlOutpatianl o Dacedenh Home
<br /> :0
<br /> ~ Saint Francis Medical Center o DOA o OthertSpaclfy)
<br />"- e ac, CITY OR TOWN OF DEATH (Includa Zip Coda) /a(\, COUNTY OF DEATH
<br /> ~ Grand Island 68803 Hall
<br /> ::::l ea. RESIDE:NCE:-STATE 1eb. COUNTY lee. CITY OR TOWN
<br /> II.
<br /> ~ Nebraska Hall Grand Island
<br /> " ed. STREET AND NUMBER /aa. APT, NO. ,'" 91.lJP C:;:~ 1 lag, INSIDE CITY LIMITS
<br /> CD ~ Yao 0 No
<br /> l;:: 823 W. 13th Street
<br /> '1:
<br /> cD lOa. MARITAL STATUS AT TIME OF DEATH 0 Mamad o Nevar Mamadll0b. NAME OF SPOUSE (FI",t, Mlddla, Lasl, sum.) If wi"', give maldan name.
<br /> I o Mamad, bOlaapa"'lad D Wldowad 00 Dlvorcad o Unknown '"
<br /> CL 11, FATHE:R'll.NAME: (Flrel, I la, MOTHER'll-NAME (Flrel,
<br /> g Middle, Last, Sufll.) Mlddla, Malden Sumame}
<br /> 0 Thomas Havs Delores Gardels
<br /> .z 13. EVER IN U.S. ARMED FORCES? Give datea of aarvlca II Yea. 14a.INFORMANT.NAME 14b. RE:LATlONSHIP TO DeCEDENT
<br /> ~ (Ves, No, or Unk.) No Alexis Boaus Dauahter
<br /> 15, MHHOD OF DISPOSITION MBALMERiJ0:4 I 1 lb. LICE:NSE NO. 11;c. DATE (Mo" Day, Yr.)
<br /> IjJ Bun", o Oonlllon 1 ,AAA. '(A -< ./; /07/ September 13, 2008
<br /> o CIlHII.tlon o Ent_bmon' 16d. CEMHE:RY, CREMATORY OR OTHER LOdl:n6N STATE
<br /> o Removal DOlnOnOpe<'Iy, CITYITOWN
<br /> Edison Cemetery Edison Nebraska
<br /> 17a. FUNE:RAL HOME NAME: AND MAILING ADDRESS (St",et, City Or Town, Stale) 17b. lJp Coda
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> CAUSE OF DEATH (See instructions and examples)
<br /> 11. PART I. e"tlr tne C!h~ln of .IfMIa' - dl......, InJu....., Qr compllc:at'on... tn. dlrKIIV C:IUltd tint de.th. 00 NOT Inlll' IlIrmln.. .....ntlllLlch ., c:arcllle; Anut, I APPROXIMATE
<br /> INTERVAL
<br /> ....pl....ory .rrett, Or ventricular nbrlll.IIDO wllhout thowtng (he 'tlology. DO NOT ABBRE\1IATI!. Enler oraly on. c:lus. Oil .llnl. Add additlonolllnll II' nec....'Y' I
<br /> IMMEDIATE: CAUSE: on.et to death
<br /> IMMEDIATE CAUSE (Final C. QJ1C e.. Y' I 3 Yea-vs
<br /> dlee... or condition re.ulUng 0) \ ) +~ 'r I ne I
<br /> In daath)
<br /> DUE TO, OR AS A CONSEQUENCE OF: I on08llo daolh
<br /> I
<br /> Saquentially 1101 condltlona, If b) I
<br /> any, laadlng to the eauoa 1I0tad
<br /> on line I. DUE: TO, OR AS A CONSE:QUENCE OF: I onael to dlll.th
<br /> I
<br /> Entar tha UNDERLYING CAUSE c) I
<br /> (dlaea.. or Injury that Inlllalad DUE: TO, OR AS A CONSEQUENCE: OF: onoatto death
<br /> Iha avente reoulllngln daoth)
<br /> LAST I
<br /> I
<br /> d) ,
<br /> la. PART II. OTHER SIGNIFICANT CONDITlONS.condlllono eonlrlbullng 10 the daath but nol reaulllng In the undanylng co"ee given In PART I, lB. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> o VES IRI NO
<br /> a:
<br /> w aD, IF FE:MALE: ala. MANNE:R OF DEATH alb.IF TRANSPORTATION INJURY ale, WAS AN AUTOPSY PERFORME:D?
<br /> ii: t8I Not pnlgnant within pu..t y..r .i:J NOlural o Homicide o DnvartOpa",lor DYES 18 NO
<br /> j::
<br /> a:: o Pregnant at time of death o Aceldanl 0 Pandlng Invasllgatlon o Paaaen""r
<br /> W 21d. WERE AUTOPSV FINDINGS AVAILABLE:
<br /> 0 o Not pregnant, but pregnant within 42 day.. of death o Suicide o Could not be det.nnlned o Pad.atnan
<br /> ;.:, TO COMPLHE CAUSE OF DEATH?
<br /> ,g o Not pregn.n~ but pregnant 43 d"'ye to 1 year before death o Dthar (S~elfy) o Yl:S oNO
<br /> ~ oUnknown If pregnant within tha paot yaar
<br /> ii I aab. TlME OF INJURV I a2c. PLACE OF INJURY-At home, fann, Olnlel, foclory, offiea building, eon'lrucUon olle, 010. (Spaclfy)
<br /> S 220, DATE OF INJURY (Mo., Day, Yr.)
<br /> 0
<br /> .z aad, INJURY AT WORK? 1 22a. DESCRIBE HOW INJURV OCCURRED
<br /> ~ DYES oNO
<br /> 221. LOCATION OF INJURY. STREET & NUMBER, APT, NO. CITYITOWN STATE lJP CODE
<br /> a3a. DATE OF DEATH (Mo., Doy, Yr.) Z a... DATE: SIONED (Mo.. Doy, Yr.) 24b. TIME OF DEATH
<br /> Z q-IO-O'h ~:$i::;
<br /> '"'-c rn
<br /> ..,- OZ
<br /> I~)- a3b, Dq ~ONibMO~DOY3 23<:. TIME OF DEATH " iij 0::: a... PRONOUNCED DEAD (Mo.. Day, Yr.) 24<1. TlME PRONOUNCED DEAD
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<br /> ...D..... 7:45 P.rn e-~o( :i rn
<br /> E ",Z
<br /> 8,,0 23d. To tha baat of my knowladge, doath oocu""d atlhe lima, data ond plaea o it:f;: 0 24e. On the bula of examination and/or Inv,atlgaUonl In my opinion death occurred
<br /> ,2:-g uWZ
<br /> and duato Ih~reandTllla) "Z:l al tha time, data and placa and duo 10 tha cauoe(O)alalad. (Slgnalura and Tltle)
<br /> ." ~~ "'00
<br /> ~tl:U
<br /> ) Sa
<br /> -; ,) 25, DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28<<. HA$ ORGAN OR TISSUE DONATION BEEN CONSIDERED? 12Gb. WAS CONSE:NT GRANTED?
<br />1<::: ) oYE:S BNO o PROBABLY o UNKNOWN tJ Yl:S ~ NO Nol Appllcoble If ala 10 NO 0 YES oNO
<br />a7. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHVSICIAN OR COUNTY ATTORNEY) (Type or Pnnl)
<br />Jennifer Brown, M.D., 729 N. Custer AVe. , Grand Island, Nebraska 68803
<br /> 2aa. REGISTRAR'S SIGNATURE kp~ L aBb. DATE: FILED ~ti1'Sn(~8 Yr,)
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