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<br /> 1.DECEDENT'S-NAME (First, Middle, Lalt, Suffix) 2.sM t., "I.' !l.'DA.TE"OF DEATH (Mo., Day, Yr.)
<br /> Emma Augusta Colman Female"" .. ,,\:. ""OCt~ber 27,2008
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE. Lalt Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. I DAYS HOURS I MINS.
<br /> Grand Island, Nebraska 81 September 21, 1927
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 506-28-3016 ~ OlnpaUent OTHER ~ Nursing Home/LTC o Hospice Facility
<br /> 8b. FACILITY-NAME (If not Institution, give street and number) o ERlOutpatlenl o Decedent's Home
<br />0::
<br />0 Grand Island Veterans Home ODOA o Other (Specify)
<br />t
<br />'w' 8c. CITY OR TOWN OF DEATH (Include Zip Code) 18d. COUNTY OF DEATH
<br />0::
<br />is Grand Island 68803 Hall
<br />..J 9a. RESIDENCE-STATE 19b. COUNTY 19c. CITY OR TOWN
<br />~
<br />w Nebraska Hall Grand Island
<br />~ ~. APT. NO. I Sf. ZIP CODE 199. INSIDE CITY LIMITS
<br />::. 9d. STREET AND NUMBER
<br />u.. 2300 W. Caoital Ave. 68803 ~YES 0 NO
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<br />11 10a. MARITAL STATUS AT TIME OF DEATH 0 MalTled 0 Never MalTled 110b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />q: o MalTled, but 8eparated ~ Widowed 0 Divorced 0 Unknown Clyde H Colman
<br />'t
<br />~ 11. FATHER'S-NAME (First, Middle, Last, Suffix) 112. MOTHER'S.NAME (First, Middle, Malden Surname)
<br />~ Manfred Carl Dittman Sophia Augusta Beyersdorf
<br />Q. 13. EVER IN U.s. ARMED FORCES? Give dates of service If Yes. T14a.INFORMANT.NAME 14b. RELATIONSHIP TO DECEOENT
<br />~ (Y88, No, or Unk.) No Roy Colman Son
<br />1J 15. METHOD OF DISPOSITION 16a. EMBALMER.sIGNATURE I 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />0 ~ Burial o Donation Chris McCoy 1191 October 30,2008
<br />I-
<br /> o Cremation 0 Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br /> o Removal o Other (Specify) Grand Island City Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 117b. Zip Code
<br /> Livingston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 68803
<br /> CAUSE OF DEATH (See instructions and examDles\
<br /> 18. PART I. Enter the chain of Iltventa. .(Ilna..., .nJuries, or compllcatlon.-thlllt dlrectl)' caused the death. DO NOT enter tllllnnlnallltY41nh auch I' cardiac arreet, APPROXIMATE
<br /> INTERVAL
<br /> respiratory arrest. or wntriCI,daf' fibrillation without showing theetlolog)'. DO NOl' ABBREVIATE. Enter only one cau.. on a lint. Add aCldnIO.,alllne. If necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Flnol a) Alzheimers Dementia > 2 Years
<br /> dIH.BH Or condition rQSultlng
<br /> In death) DUE TO, OR AS A CONSEQUENCE OF: on8et to death
<br /> Soquontlally 1101 conditions. If b)
<br /> any, leading to the CollUM IItrted
<br /> on Un. ,jI. DUE TO, OR AS A CONSEQUENCE OF:
<br /> onset to death
<br /> Entor tM UNDERLYING CAUSE c)
<br /> (dlsoa.. or Injury thatlnhlalod
<br /> tho oven.. ...ulllng In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> LAST d)
<br /> 18. PART II. OTHER SIGNIFICANT CONDITIONS-Condltlonl contributing to the death but not resulting In the underlying cau8e given In PART I. 19. WAS MEDICAL EXAMINER
<br /> Recurrent Urinary Tracllnfeclion OR CORONER CONTACTED?
<br />0:: DYES ~ NO
<br />w 20. IF FEMALE: 21a. MANNER OF DEATH 21b.IF TRANSPORTATION INJUR 21 c. WAS AN AUTOPSY PERFORMED?
<br />ii:
<br />~ o Not pregnant within past year ~ Natural o Homicide o Driver/Operator DYES ~ NO
<br />w o Pregnant at time of death o Accldont o Pending Inwstlgatlon o Passenger
<br />U
<br />~ o Not pregnant, but pregnant wtthln 42 day. of death o Suicide o Could not bII determined o Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />o Not pregnant, but pregnant 43 day. to 1 year before death o Othor (8peclfy) TO COMPLETE CAUSE OF DEATH?
<br />~ o unknown If pregnant within the past year DYES o NO
<br />Q. 22a. DATE OF INJURY (Mo., Day, Yr.) 122b. TIME OF INJURY T22C. PLACE OF INJURY.At home, farm, street, factory, office building, construction 81te, etc. (Specify)
<br />E
<br />8
<br />1J 22d. INJURY AT WORK? r2e. DESCRIBE HOW INJURY OCCURRED
<br />~ DYES ONO
<br /> 221. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYfTOWN STATE ZIP CODE
<br /> 23.1. flATE OF DEATH (Mo., Dsy, Yr.) ..-- - ~ .. ..- :24.. tlATUIGNI:D (iio~ Day, Yr:, f4b. TIME OFl)EATH
<br /> ~~ October 27, 2008 lr~i
<br /> i~>- 23b. DATE SIGNED (Mo., Day, Yr.) 1 23c. TIME OF DEATH j1tl 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> November 4, 2008 09:05 AM !~~~
<br /> f..;;j E"i~
<br /> B go 0 3d. To the b.tt of my knowledge. death occurred at the time. date ....d place BIl: 2048. On the ba,l, of examination and/or InveltlQaUon, In my opinion death oe:e:ufT8d at
<br /> ! :g ond dutto tho ..usols) .....d. (SlgnotulO and Tnlt' .z~o the time, date and place and due to the caUH(.) atated. (Signature and Title)
<br /> ~ ~ Jennifer King, MD ~li!u
<br /> 8 l;
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 126a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? II 26b. WAS CONSENT GRANTED?
<br /> DYES ~ NO o PROBABLY 0 UNKNOWN DYES l&I NO Not Applicable If 26a Is NO 0 YES o NO
<br /> 27. NAME, R IA"N, UNI T ype or prlntf
<br /> Jennifer King, MD, 2300 West Capital Avenue, Grand Island, Nebraska, 68803
<br /> 28a.REGISTRAR'SSIGNATURE .N.... <'"..- A- r;., "..~ I 28b. DATE FILED BY REGISTRAR (Mo" Day, Yr.) I
<br /> 'V - November 5, 2008
<br /> , (J
<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH.,I4<<a.NJ:JM/!r.~ER\1ICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGI1'!41:."liiC;fjfJP. ., WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STIfI7!!..."'I/!S'$E.C "J WH'JqIf IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. '~:~' ~..,....~';\.Tj 'j,J2;~ I iiy
<br />
<br />DATE OF ISSUANCE ,.(1..... ~ j
<br />200 90 0 0 6 9 ;, ;i j'p,NL,fY". aO(J~R :
<br />11 /06/2008 .~ .~ISt TJDft uqlS!1fl1~
<br />LINCOLN, NEBRASKA l J;I~R'H AND HUMA~:$IIil!I!FFS:
<br />
<br />STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUM~~~~~~~DA {>,~~\....~< ;~'/
<br />CERTIFICATE OF DEATH \ l ,\/ ..... .... , \\\l ""..
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<br />08 01622
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