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<br />1. DECI"DENT'S-NAME (First,
<br />Mary Josephine Denman
<br />
<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 ON FIl"E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS.SECTlr;JN, WHICH IS
<br />
<br />:::;::~~:::::~TORY FOR VITAL RECORDS. ~...., '. ..... ........:'....:,'it;!~..'. '.... '. ...t,": ' ;,
<br />
<br />'.,':":"" ,I\.)I~" .. ( , '....'i:,.). l.r,.
<br />
<br />OCT 1 8 2007 200810297 ," ,~,~, .T~r:n:!!'f.S.cpqfJ.fEf,!,.
<br />." ASS/~~NJ:'S~t1$.;?i'tEG~'i~R:,
<br />LINCOLN, NEBRASKA HEALrH,^NDHUMAfl-S~tlJCj;Sf;_
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE~Nb SlJI'iF'dI'lT:, T' '.,' .,. ~}
<br />CERTIFICATE OF DEATH ..' ~, :.' ~), A_, it';,;/ .
<br />Lasl, Sullix) 2, SEX ..... "~'. "",3'iDATEOFDl'ATH ~9'"bay':,Yr,)
<br />Famall:! '(:"".;':it\q \l-t~e.'2Gr6z>':'
<br />Sa, AGE-Last Birlhday Sb, UNDER 1 YEAR 5e, UNDE'il' I DII'Y.- ,,6: Dl\l~ OF'BlmH'tMo,.;,tiay, Yr,)
<br />(Yrs,) MOS, DAYS HOURS MINS;,,' 'l.,'"''-",,: ..".
<br />
<br />Mlddlo,
<br />
<br />Q
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Grand Island, Nebraska
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />83
<br />Sa, PLACE OF DEATH
<br />
<br />~:
<br />
<br />Nbveiribe'r 6, 1923
<br />
<br />505-22-7613
<br />8b, FACILITY-NAME (II not Instllutlon, giv~ slre~1 and nurnMr)
<br />
<br />o Inpallenl
<br />
<br />,
<br />illl::!EB: Qg Nursing Horne/LTC 0 Hospice Facility
<br />
<br />g
<br />u
<br />W
<br />a:.
<br />2i
<br />...J
<br /><(
<br />a;
<br />w
<br />:0:;
<br />=>
<br />IL
<br />i
<br />..,
<br />~
<br />~
<br />'2
<br />..
<br />1i
<br />E
<br />8
<br />
<br />o ER/Oulpatlonl
<br />
<br />o DeCedent's Horn.
<br />
<br />Tiffany Squ<,!re Care Center
<br />Bc, CITY OR TOWN OF DI"ATH (Includo Zip Codo)
<br />
<br />Di:DI\
<br />
<br />o blher(Specity)_-----'--_~.."__
<br />
<br />Bd, COUNTY OF DI"ATH
<br />
<br />Grand Island 68803
<br />9.. RESIDENCE-STATE
<br />
<br />Nebraska
<br />9d, STREET AND NUMBER
<br />
<br />Hall
<br />
<br />
<br />Hall
<br />
<br />9b, COUNTY
<br />
<br />91. ZIP CODE
<br />
<br />9g, INSIDE CITY LIMITS
<br />~ YES 0 NO
<br />
<br />1314 W Charles 68801
<br />1Q~.,MARI.TALStl-\l us Af TIME OF DEATH CJ Married 0 Never Marned IlOb. NAME OF SPCUSE (Firsl, Mlddlal. Lasi, SJffI~J It wife, give rnaldO:1 rla:nij,
<br />
<br />o Marnod, bul separalea (Jil Widowed a DIVOlcod 0 Unknown
<br />
<br />Robert Denman
<br />
<br />..
<br />al
<br />~
<br />
<br />11,FATHEH'S-NAME (Flrsl,
<br />Phili Rose
<br />13. EVER IN U.S, ARMED FORCES? Glvo dalos 01 selVicollyes, 14a,INFoRMANT.NAME
<br />
<br />Mlddlo,
<br />
<br />Lasl,
<br />
<br />Sulllx)
<br />
<br />12, MOTHER'S-NAME (Flrsl,
<br />Dora Vocke
<br />
<br />Middle,
<br />
<br />Malden Surnarne)
<br />
<br />o erernalion 0 Entornbrnonl
<br />
<br />16a, CEMUI"RY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY / TOWN
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Dau hter
<br />
<br />16e, DATE (Mo" Day, Yr,)
<br />
<br />August27,2007
<br />
<br />STATE
<br />
<br />ail Burial
<br />
<br />
<br />16b, LICENSE NO,
<br />1/43
<br />
<br />(Yes, no, or Unk,) No
<br />IS. METHOD OF DISPOSITION
<br />
<br />o Donallon
<br />
<br />iJ Aernoval 0 Olher (Speclly)
<br />
<br />WeslIawn Memorial Park
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (SIreel, Clly or Town, Slate)
<br />Livingston.Sondermann Funeral Home, 601 N, Webb Road, Grand Island, Nebraska
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />17b, Zip Code
<br />68803
<br />
<br />CAUSE OF DEATH (See Instructions and examples
<br />16, PART I. Enler Ihe cnaln 01 "Ventsndisoasas, Injurias, or cornplleallon'nthal diroclly causod tho dealn, DO NOT onlor 10lrninalavenls such as cardiac a".SI,
<br />resplralory ."OSI. orvonlricular flbrlllallon wltnoul showinglha otiology, DO NOT ABBREVIATE, Enloronly one cause on a line, Add addltionallinos it necessary,
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE (Fnal
<br />aiiease cr (;:or.diliOnla~IBI~
<br />n doath)
<br />
<br />)("1MEDIATE CAUSE:
<br />
<br />(a) 'De~eh.\-\o...
<br />
<br />DUE TQ, OR AS A CON&EOUENCt: 01':
<br />
<br />onsollo deatn
<br />
<br />:Xy~
<br />
<br />I
<br />oii~~i Iv r.:ca~:
<br />
<br />Sequenllelly IIsl conditions, 11
<br />any,ltedlng 10 the cause IIsled
<br />on linea.
<br />Enter 1110 UNDERLYING CAUSE
<br />(disease or Injury thet Inlllaled
<br />the evenlo ,nulling In deolh)
<br />lAS1"
<br />
<br />(b)
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />on.el to dealh
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />OI1sello death
<br />
<br />(a)
<br />)t!l. PART II, OTHER SIGNIFICANT CONDITIONS-Conditions conlribuling 10 the dealh bul norrosulllng In Iho underlying cause gIVen In PART L
<br />
<br />a:.
<br />uJ
<br />u:
<br />~
<br />w
<br />u
<br />i
<br />-g
<br />'Iii
<br />ii'
<br />E
<br />c3
<br />
<br />, IF FEMALE:
<br />~Ol prognanl wllhln past year
<br />o Prognant alllrne 01 death
<br />o 1'101 pr.gnanl, but prognanl wllhin 42 days 01 death
<br />o Nol pregnant, but pregnanl43 days 10 I yoar belore death
<br />o Unl\ilO\~n IllJl~lj"lant wilhln the pS$1 y~ar
<br />
<br />o AeeldentO POndlng Invosligation
<br />U Suicide 0 COUld nol bo dolonnlnod
<br />
<br />21b, IF TRANSPORTATION INJURY
<br />o Driver/Operalor
<br />
<br />o Passenger
<br />
<br />U Podoslrlan
<br />
<br />o Othor (Speelly)
<br />
<br />19, WAS MEDICAL EXAMINER
<br />DR CORONER CONTACTED?
<br />o YES NO
<br />
<br />21c, WAS AN AUTOPSY PERFORMED?
<br />
<br />\-\,-\~f"l\G\l~
<br />
<br />Os
<br />
<br />j
<br />
<br />~, t.4~ER OF DEATH
<br />)'(tIalural a HomiCide
<br />
<br />DYES
<br />
<br />:ltl NO
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYeS lJ IW
<br />
<br />DYES 0 NO
<br />
<br />
<br />22a, DATE OF INJURY (Mo" Day, Yr,)
<br />
<br />22b, TIME OF INJURY 220, PLACE OF INJURY.AI horno, la,rn, stroat, lactory, olliee building, tonSlruclion sile, alc. (Spacily)
<br />rn
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<br />.,
<br />....
<br />
<br />l2(J.I~~JlJHr AT WOH.K.'?
<br />
<br />~2r. i..OCATi0r: OF I N":U RY . STREEi t. NUMBER, At-~i. NO.
<br />
<br />CiTaTOWN
<br />
<br />STATE
<br />
<br />ZIP COOt:
<br />
<br />a. DATE OF DEATfj..(~o" Day, Yr.)
<br />... d\o--Ci,
<br />
<br />24a, DATE SIGNED (Mo" Day, Yr,)
<br />
<br />24D, TIME OF DEATH
<br />
<br /><'-\.m
<br />
<br />z,..
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<br />n~a:
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<br />'6.Q.i(~
<br />~~1:i5
<br />owz
<br />"z::>
<br />-"00
<br />{2rr.u
<br />o ~
<br />00
<br />
<br />m
<br />
<br />z
<br />...<(
<br />-"[i
<br />al-
<br />'Ol~
<br />'E.::I:~
<br />t;:""z
<br />B ~O
<br />J.:'g
<br />0"
<br />0----
<br />:0:
<br />
<br />~. DATE SIGNED (Mo" Day, Yr,)
<br />q...
<br />
<br />ill(\" To Ine best 01 rny knowledge, dealh occurred althe IIrne, dale and place
<br />!'--' and d 10 lno causo(s) slaled, (SignalUle and Tille)"
<br />
<br />23e. TIME OF DEATH
<br />0'":55
<br />
<br />24c. PRONOUNCED DEAD (Mo" Day, Yr,) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />
<br />240, on the basis oloxaminaaon and/or InvostigaUon, In my opinion dealn OCCurrod al
<br />Iho Umo, dalo and placo and due 10 Iho cause(s) .Ialed, (Slgnatwe and TIUo)"
<br />
<br />AS CONSENT GRANTED?
<br />
<br />1'101 Applicable It 26a Is NO 0 YES NO
<br />
<br />28b, DATE FILED BY REGISTAAR (Mo" Day, Yr.)
<br />
<br />SEP 1 2 Z007
<br />
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