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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD..9-'t..f/~E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTlCS_~~1f~~c.IS
<br />
<br />
<br />::::::~:E~RYFOR vrrALRECORDS ~~~\
<br />
<br />. APR 1 2 2007 20080 96 2 8 ASSIS~iNT s~~~#tl~Aif ~,~
<br />LINCOLN, NEBRASKA HEALTffAND.~U'!'..A"'SERI/1~? .u
<br />STATEOFNEBRASKA-DEPARTMENTOFHEALTHANDHUMANSERVICESFI~NC, 9ND,'" , ,= ,t I,yeS''''' -7?
<br />CERTIFICATE OF DEATH -~.",: :..~'"" _" "'0 L
<br />- -'- '.'"-' ~j),.\fE OF DEATH (1.10.. Day, Yr.)
<br />March 25, 2007
<br />
<br />1. DECEDENT'S.NAME (Flrsl.
<br />ReUa Rae Andrews
<br />
<br />Middle.
<br />
<br />La.st,
<br />
<br />Sullix)
<br />
<br />2. SEX
<br />Female
<br />
<br />4, CITY AND STATE DR'TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a. AGE.Lasl Blrlhday 5b. UNDER 1 YEAR
<br />(ns,) MOS. DAYS
<br />
<br />50. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6, DATE OF BIRTH (1.10.. Dav. Yr.)
<br />
<br />
<br />Minden, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />70
<br />
<br />ea. PLACE OF DEATH
<br />
<br />508-40-1533
<br />
<br />D Inpollenl
<br />
<br />Qllilll: I!I Nursing HomelL TC D Hospice Facility
<br />
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<br />
<br />Bb. FACILITY-NAME (If nol Institution, glv. stre.1 and number)
<br />
<br />D Dectdenrs Horn,
<br />
<br />D ERlOulpallenl
<br />
<br />D [0\ D Oll1erlSpeclly)
<br />8d. COUNTY OF DEATH
<br />
<br />51. Francis Memorial Health Center LTC
<br />
<br />8c. CITY OR TOWN OF.DEATH (Include Zip Code)
<br />
<br />Grand Island 68803
<br />8a. RESIDENCE.STATE
<br />
<br />
<br />Bg.INSIDE CITY LIMITS
<br />
<br />Ii YES D NO
<br />
<br />9b. COUNTY
<br />
<br />Nebraska
<br />Sd. STREET AND NUMBER
<br />
<br />4318 Marian Road
<br />lOa. MARITAL STATUS AT TIME OF DEATH D Married D Never Mamed
<br />
<br />Hall
<br />
<br />81. ZIP CODE
<br />
<br />68803
<br />lOb. NAME OF SPOUSE (Flrsl. Middle, la.l, Sulllx) II wile, give maiden name.
<br />
<br />D Merned. bul separaled III Widowed D Divorced D' Unknown
<br />
<br />Merrill Andrews
<br />Sulllx) 12. MOTHER'S-NAME (Filii,
<br />
<br />Sadie Schneider
<br />
<br />11. FATHER'S-NAME (Flrsl,
<br />Harold McAtee
<br />
<br />Mlddla,
<br />
<br />Last,
<br />
<br />Middle,
<br />
<br />Malden Surnama)
<br />
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dalaa 01 sarvlcall ves.
<br />IYas, no, Or unk.) No
<br />15. METHOD OF DISPOSITION
<br />lEI Burla' D Donellon
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Son
<br />16c. DATE (1.10" Day, Yr.)
<br />
<br />March 29, 2007
<br />
<br />STATE
<br />
<br />D CmmaUon D Enlombmanl
<br />o Removal 0 Olhar (SpaCllvl
<br />
<br />?
<br />16d. CEMETERY, CREMATORY OR OTHER L
<br />
<br />parkview Cemetery
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreel, City or Town, Slole)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />Hastings
<br />
<br />Nebraska
<br />17b. Zip Coda
<br />68801
<br />
<br />CAi nst ruet icnll...an d!x.ampllls)
<br />18, PART I. Enler Ihe chain 01 evenls..dlseeses, InJuries, or compllcallons--Ihal dlrecllv caused Iha dealh, DO NOT anler lermlnal even Is such aa cardiac arreal
<br />resplralory a"esl, orvanlrleular lib rille lion without showlhg Ihe eUology. DO NOT ABBREVIATE. Enleronly one cause on a IIna.Add eddlllonalllnes II naeenary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />I
<br />
<br />::T;CAUSGzIl n1Je~s!aWc N~~fOQtAJJth~r~s~,ew~~a3 03IO;;~~
<br />
<br />IMI~EDIA TE CA USE (Fhel
<br />dllea.e or condRIon relURIng
<br />h deelh)
<br />
<br />Sequ,nllollJ I"tcondlllon., K (b)
<br />1nY,IIIdlnlllo Ih.ceun H.t.d DUE TO, OR AS A CONSEQUENCE OF:
<br />on IIn..,
<br />Enllr.... UNDERlYtlQeAUS~
<br />(dl.e..eor hJury Ihat hllletad (c)
<br />lh.evenlBrllullnghdulh) DUE TO, OR AS A CONSEQUENCE OF:
<br />lASf
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsello death
<br />
<br />onsalto daath
<br />
<br />onsello dealh
<br />
<br />(d)
<br />
<br />
<br />f(pVlQj)
<br />
<br />1TI0Ns~condlllon',conlr1bullng 10 lha dealh bUl not resulllng In Iha underlying eau.a given In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />D YES NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
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<br />
<br />{1. 22d.INJURY ATWORK?
<br />
<br />20. IF FEMALE:
<br />
<br />1Ii Nol pregnanl wllhln pasl vear
<br />
<br />D Pragnonlal Umeol dealh
<br />
<br />o Nol pregnanl, bul pregnenl wHhln 42 days 01 dealh
<br />
<br />o NOI pregnonl, bul pregnenl43 davslo 1 year belore dealh
<br />
<br />D Unknown II pregnanl wHhln Ihe p.sl year
<br />
<br />210. MANNER OF DEATH
<br />::,d Nalural D HomiCide
<br />
<br />21b.IF TRANSPORTATION,INJURY
<br />D Drlver/Operalor
<br />
<br />D Passenger
<br />
<br />D Pedeslrlan
<br />
<br />D Oll1ar (SpecIIV)
<br />
<br />DYES
<br />
<br />)d NO
<br />
<br />D AccldenlD Pending InvasUgallon
<br />D Sulclda D Could nOI ba delermlned
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES NO
<br />
<br />22a. DATE OF INJURY (1.10" Day, Yr,)
<br />
<br />22b, TIME OF INJURY 22c, PLACE OF INJURY-AI homa. larm, slreel, 'eclory, olnce building, conslrucllon sHa, elc. (Spaclly)
<br />m
<br />
<br />22a. DESCRIBE HOW INJURY OCCURRED
<br />
<br />DYES D NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />z
<br />i;'S
<br />is!
<br />Gig!
<br />1i.::r:!:i
<br />Eo..z
<br />B goo
<br />..'5
<br />"'''
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<br />00:
<br />
<br />23a. DATE OF DEATH (1.10" Day, Yr.)
<br />March 25 2007
<br />
<br />m
<br />
<br />24.. DATE SIGNED (1.10" Day, Yr.)
<br />
<br />24b. nME OF DEATH
<br />
<br />~i:i
<br />ii'oz
<br />ling
<br />]~l:
<br />0. a.. Ii( ~
<br />E."' >- Z
<br />Bffi!;eo
<br />"Z::>
<br />"'00
<br />~a:;O
<br />815
<br />
<br />
<br />23c, TIME OF DEATH
<br />
<br />7:55 p.m
<br />
<br />23d. To Ina baSI or my knowledge, death occurrad ellhe lima, dale and place
<br />and due 10 Ina cause(s) slaled. (Slgnalura ano Tille) T
<br />
<br />i?Jiih r l4t) # /S/ f77
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24a. On the basis 01 exam/nollon ondlor Inve.llgallon.ln my opinion daalh occurred al
<br />Ihallme, dale and place and dualo tha causa(s) staled. (Slgnalu,. and Tille) T
<br />
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />D YES ~ NO D PROBABLY D UNKNOWN D YES ~NO
<br />27. ~AME, TITLE AND ADDRESS OFCEATIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (l'ypeorPnnl)
<br />R1Chard Fruehling, M.D., 2116 W; Faidle
<br />
<br />2ea. REGISTRAR'S SIGNATURE
<br />
<br />2Gb. DATE FILED 8Y REGISTRAR (1.10" Day, Yr.)
<br />
<br />APR 6 2007
<br />
<br />2Gb. WAS CONSENT GRANTED?
<br />Nol Applicable 1126. Is NO DYES
<br />
<br />NO
<br />
<br />
<br />
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