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<br />
<br /> STATE OF NEBRASKA
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND'HUMAN SERVICES
<br /> SYSTEM, IT CERTIFIES THE BELOW TO BEA TRUE COPY OF THE ORIGINAL 1f1L'E,WITH
<br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST,( S~ l(I;MV, W OCH IS
<br /> THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br /> 4 i
<br /> DATE OF ISSUANCE ~~,J~~~~~~"`//
<br /> y: E/Y S; COO
<br /> JUL 0 8 2008 aAISra ~ErrsrR~a
<br /> LINCOLN, NEBRASKA 00 Q 0305 Q 4AWAUD HIJMgN SEA.
<br /> 1177 V ppy"°Y
<br /> Ivbl. Y~
<br /> STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVIQtS HNI,f C PPt+119 3~1JI;PQ 1
<br /> CERTIFICATE OF DEATH
<br /> 1- DECEDENT'S-NAME (First, Middle, Last, suffix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br /> Kenneth Raymond P0 e Male June 28, 2008
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr,)
<br /> (Yrs.) MOS. DAYS HOUg5 MINS.
<br /> Thief River Falls, Minnesota 92 October 15, 1915
<br /> 7. SOCIAL SECURITY NUMBER Be. PLACE OF DEATH
<br /> 470-18--9418 HOSPITAL: ❑ Inpatient QM El Nursing Home/LTC Q Hospice Facility
<br /> Bb. FACILITY-NAME (If not institution, give street and number)
<br /> Ell ER/Oulpetlent ~ Decedent's Home
<br /> 3990 W. Capital Ave. 11213 Q DD4 ❑Olher(Speclly)
<br /> Go. CITY OR TOWN OF DEATH (Include Zip Code) Bd. COUNTY OF DEATH
<br /> Grand Island 68803 g
<br /> Sa. RESIDENCE-STATE 8b. COUNTY 8c. CITY OR TOWN
<br /> Nebraska Hall Grand Island
<br /> gd. STREET AND NUMBER Be. APT. NO 8f. ZIP CODE 9g, INSIDE CITY LIMITS
<br /> 3990 W. Capital Ave. 158803 (k YES ❑ NO
<br /> 10a. MARITAL STATUS AT TIME OF DEATH R Married Q Never Married 10b. NAME OF SPOUSE (First, Middle, Lest, Suffix) If wife, give maiden name.
<br /> Q Married, but separated Q Widowed © Divorced Q Unknown
<br /> Gean (Carlson) Pope
<br /> 11. FATHER'S•NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br /> Henry Raymond Pope Hattie Francis Smith
<br /> 13. EVER IN U.S. ARMED FORCES? Give dates of service If yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yes, no, or unk.) No Gean Pope _ e
<br /> 15. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE tBb. LICENSE NO. 160. DATE (Mo., Day, Yr. )
<br /> ❑Burial QDonation Not Embalmed June 30, ?0n8
<br /> Cremation Q Entombment tad. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> Q Removal 0 Other (Specify)
<br /> Westlawn Cremator Grand Island NE
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stale) 17b. Zip Code
<br /> Livingston-Sondermann F.H., 601 N. Webb Rd. Grand Island NE
<br /> 18. PART 1. Enter the chain of events-diseases, injuries, or compllcelions--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br /> I
<br /> respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE- Enter only one cause on a line. Add additional lines if necessary. I
<br /> IMMEDIATE CAUSE: I onset to death
<br /> A/I1 d I
<br /> IMMEDIATE CAUSE (Final (a) e~aS~a~1G /V1r4.1i N4'n~ e p E~1OIM~1 ~~1N I c2 dlkA
<br /> disessearcondillvnrasulting DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br /> In death).
<br /> S"uentlally [let conditions, If
<br /> any, leading to the cause listed -D-VETO, GRAS A CONSEQUENCE OF: I onset to death
<br /> on line a.
<br /> Enter the UNDERLYING CAUSE
<br /> (dlseass or injury that Initiated (c)
<br /> the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br /> LAST
<br /> I
<br /> (d)
<br /> 18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given in PART I, 421c.WASAN MEDICAL EXAMINER
<br /> by ts ea ORONER CONTACTED?
<br /> G~nrV AtiC mb5fftC-'FII,> - P1L114490M0 D i
<br /> se
<br /> ES R
<br /> ~R NO
<br /> 20. IF FEMALE: 21a. MANNER OF DEATH 21b.IFTRANSPORTATIONINOPSYPERFORMED?
<br /> ❑ Not pregnant within past year 7L XNatural ❑ Homicide ❑ Driver/Operator
<br /> ❑ Pregnant et time of death CI Accldenif❑ Pending Inveetlgellon C1 Passenger 3~"NO
<br /> Q Not pregnant, but pregnant within 42 days of death ❑ Suicide C3 Could not be determined ❑ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br /> U Not pregnant, but pregnant 43 days to 1 year before death Q Other (Specify) COMPLETE CAUSE OF DEATH?
<br /> ❑ Unknown it pregnant within the past year Q YES <NO
<br /> 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c, PLACE OF INJURY-AI home, farm, street, factory, office building, construction site, etc. (Specify)
<br /> m
<br /> 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br /> ❑ YES ❑ NO
<br /> 22f. LOCATION OF INJURY - STREET a NUMBER, APT. NO. CITY?OWN STATE ZIP CODE
<br /> 3a. DATE OF DEATH (Mo., Day, Yr.) Y 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIME OF DEATH
<br /> to-a9-0V 5tA In
<br /> Ii23b.DATE SIGNED (Mo.Day, Yr,) 23c.TIMEOFDEATH } 24c. PRONOUNCED DEAD (Mo.. Day. Yr.) 24d. TIME PRONOUNCED DEAD
<br /> 8i ~°'3d-Q q:1 m m
<br /> n9
<br /> 23d, To the best of my knowledge, death occurred at the time, date and place 24a, On the basis of examination and/or Investigation, in my opinion death occurred at
<br /> 2 and due to the cause(s) staled. (Signature and Title) r g 8 the time, dale and place and due to the cause(s) staled. (Signature and Title) T
<br /> 04 15
<br /> $,25.'DIDTOBACCO USE CONTRIBUTE TO THE DEATH? Via. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 266, WAS CONSENT GRANTED?
<br /> ❑ YES V NO Q PROBABLY 0 UNKNOWN ❑ YES ~ NO Not Applicable if 26a is NO ❑ YES ~ NO
<br /> 7. N qyTITI ANDAD RES$ CERTIFI (W YSICIAN,CORONER'SPHYSIC NRR NTYA ORNEY) (Type or Print)
<br /> ~
<br /> X? / he,rw lrru¢if" al~~v tv~~~' ~D~ ran
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> JUL 3 2008
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