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<br />STATE OF NEBRASKA
<br />
<br />~
<br />
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL TH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEf.,,\RTMENT OF HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VJtJ!.L"f1.E1CQItD5.
<br />'. ". ~ \ , I . ':(. " L~_ __
<br />DATE OF ISSUANCE . ',.) <"'~" !J6"~~
<br />I StANLB:r s. COOPER ". .,'
<br />
<br />JANu:C~L~O~:BRASKA 2009009 40 .: iJJ,~'ii:~~":.f
<br />
<br />
<br />" :~"~"" " .' ':'C:,~I .:';'
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALT.HAND HUMAN SERVICES FINA~CE AND ;,.~fp&/P..;.8' ..' 3'~ 1d'g:' 0
<br />_~ CERTIFICAtE OF DEATH : , ,\) 'I' U . J-U_ _
<br />~ \, ..:;
<br />" . 3. DAfE OF DEAtJj,'(Mo., Day, Yr,)
<br />Decemoer 26, 2008
<br />6. DATE OF BIRTH (Mo;, Day, Yr.)
<br />August 19, 1938
<br />
<br />1.DECEDENT'S.NAME
<br />
<br />(First,
<br />
<br />Mlddl.,
<br />Eugene
<br />
<br />La.t,
<br />Bellam
<br />
<br />SUffix)
<br />
<br />2, SEX
<br />
<br />Larry
<br />
<br /> -.~~""~ -
<br />RITORY, OR FOREIGN COUNTRY OF BIRTH 5.. AGE.L..t Blrloday
<br />d, Nebraska (Yrs.)70
<br /> ._'~,.~.,-_. -." -~ ---
<br />R ea. PLACE OF DE
<br /> 1iQSfJIAL:
<br />not Institution, give stteet and number)
<br />are Care Center
<br /> ."
<br />
<br />
<br />Male
<br />
<br />4, CITY AND STATE OR TER
<br />
<br />Grand Islan
<br />
<br />7. SOCIAL S~CURITY NUM8E
<br />506-48-7662
<br />
<br />ATH
<br />
<br />o Inpall.nt
<br />
<br />0lI:Ili8: CXNurslng Hom./LTC D Hospic. F.cillty
<br />
<br />eb. FACILITY-NAME (If
<br />Tiffany Squ
<br />
<br />D ER/Outp.tl.nt
<br />
<br />[:J Decedent's Home
<br />
<br />D lXl'\ D OIo.r (Speclly)
<br />ec. CITY OR TOWN OF DEATH (Includ. Zip Code) Bd, COUNTY OF DEATH
<br />Grand Island, Nebraska Hall
<br />9., RESIDENCE.STATE '--"-J 9b. COUNTY
<br />Nebraska Hall
<br />--',-",,_.~
<br />
<br />
<br />99. INSIDE CITY LIMITS
<br />DYES mI: NO
<br />
<br />91. ZIP CODE
<br />1418~ W. Airport Road 68824
<br />10.. MARITAL STATUS ATTIME OF DEATH aiM.rrled D N.v.r Marrl.d lOb. NAME OF SPOUSE (Firsl, Middle, La.t, SulIl,)II wifa, give mald.n n.m..
<br />
<br />Q Divorced 0 Unknown
<br />
<br />Alice Hindmarsh
<br />
<br />11, FATHER'S.NAME (First,
<br />Elmer
<br />
<br />Middle,
<br />J.
<br />
<br />L.st,
<br />Bellamy
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S-NAME (Flrsl,
<br />Lucille
<br />
<br />Middle, M.ld.n Surname)
<br />
<br />Myers
<br />
<br />14~, RELATIONSHIP TO DECEDENT
<br />
<br />Wife
<br />
<br />13. EVER IN U.S. ARM~D FORCES? Glv. dal.s 01 s.rvic.11 ya.. 14a,INFORMANT.NAME
<br />(V.s, no, OJunk.) No Alice Bellamy
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />o Burial
<br />
<br />D Dona lion
<br />
<br />16.. EMBALMER-SIGNATURE
<br />Not Embalmed
<br />
<br />16d, CEMETERY, CREMATORY OR OTHER LOCATION
<br />West lawn Cemeeery Crematory
<br />
<br />lab. LICENSE NO.
<br />
<br />Xltremallon D Entombm.nl
<br />o R.mo,.1 D omar (Specily)
<br />
<br />CITY /TOWN
<br />Grand Island
<br />
<br />t6c. DATE (Mo., Day, Yr,)
<br />Decembe~...?9, 2008
<br />STATE
<br />Nebraska
<br />
<br />~ ~,~'.~~-
<br />11a, FUNERAL HOME NAME AND MAILING ADDRESS (Streel, CityorTown, SI.I.)
<br />
<br />Apfel Funeral Home
<br />
<br />1123 West 2nd Street
<br />
<br />Grand Island, NE
<br />
<br />176886ra
<br />
<br />18. PART I. Enter the chain of AVP.nlsndiseasBs, Injuries, or complicationsnthat directly caused Ihe death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, Or ventricular flbrlllallon without showing the etiology. DO NOT ABBREVIATE, Enter only one cause on a line. Add addlllonalllnes If necessary,
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUS~'
<br />
<br />onset to death
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl..... or cond"lon re.ufting
<br />IndlOlh)
<br />
<br />(a) 'Mn ~ l.I.AA ~ Cn'I.\.t....
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(gLvi,J
<br />
<br />Onset to death
<br />
<br />S.qu.nllally 11.1 conditions, II (b)
<br />any. leading loth.clU..lIs..d DUE TO, OR AS A CONSEQUENC~ OF:
<br />on line a.
<br />Enl.rlh. UNDERLVING CAUSe
<br />(dl..... or Injury th.t InltlatOd (cl
<br />:;v.ntareaultlng In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on$ello death
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS.Condltlons contributing to the d.ath but not resulting In Ih. underlying caus. givan in PART I.
<br />
<br />20. IF FEMALE:
<br />Q NOI pregnant within past year
<br />o Pregnant at tima of death
<br />o Not pregnant, bUI pregnant within 42 days of dealh
<br />o Not pregnant, but pregnant 43 days 10 1 year before death
<br />[J Unknown jf pregnant within the pas! year
<br />
<br />21 a. MANNER OF DEATH
<br />!l9.N.tural D Homicide
<br />
<br />o Accld.ntD P.ndlng Inv..ligsllon
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />DYES j( NO
<br />21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />C-of'P
<br />
<br />o SuicIde 0 Could not be dalarmlned
<br />
<br />D P....ng.r
<br />D P.d..lrlan
<br />D other (Specily)
<br />
<br />DYES ClNO
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />_.. l DYES D NO
<br />
<br />22a, DATE OF INJURY (Mo., D.y, Yr,)
<br />
<br />22b. TIME OF INJURY 22c, PLACE OF INJURY.At hom.,I.rm, str..I, f.clory, ollice building, construclion sit., .Ic. (Sp.clfy)
<br />
<br />m
<br />
<br />22d, INJURY ATWORK? -or '2'2.', DESCRIBE HOW INJURY OCCURRED
<br />
<br />__~::~J.
<br />
<br />221, LOCATION OF INJURY. STREET & NUMBER, APT. NO, CITYITDWN
<br />
<br />SWE
<br />
<br />ZIP CODE
<br />
<br />24a. DATE SIGNED (Mo.. D.y, Yr,)
<br />
<br />24b. TIME OF DEATH
<br />
<br />230. TIME OF D~ATH
<br />/100 m
<br />
<br />z>
<br />~~!l!
<br />i~~
<br />lfi(~
<br />~~~ES
<br />1l~:>
<br />,2l!i~
<br /><.>0
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIM~ PRONOUNCED DEAD
<br />m
<br />
<br />23d. To the best of my knowledge. death occurred at the time, date and place
<br />and due to the eause{s) staled. (Signature and Tille)"
<br />
<br />~'1l J--
<br />
<br />248. On the basis of examination and/or investigation, in my opinion death OCcurred at
<br />the time, da.te and place and due to the cause{s) Slated. (Signature and Title) ...
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />2e.. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />2eb, WAS CONSENT GRANT~D?
<br />
<br />~~~~__q~9 D PROBA~Y .__g,I!..~~~C:>.WN D YES __~._____ ii(.NO __ __
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. or Print)
<br />Anne Morse M.D. 729 N. Custer Ave., Grand Island, NE
<br />
<br />28.. REGISTRAR'S SIGNATURE
<br />
<br />Nol Applic.bl. 112e. i. NO DYES IiiC NO
<br />
<br />68803
<br />
<br />J
<br />
<br />
<br />2Bb, DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />
<br />JAN J 2009
<br />
<br />HHS-61 11/03 (55061)
<br />
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