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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL pF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA Q~`TMENFT, OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL""RF~~•Q, D~$.;' ~, .' ~ ;
<br />11 _ - "
<br />DATE OF ISSUANCE ~ •(
<br />~~rd~d~~a ` ~,
<br />STANLEY.•S. C~O~~F~,,,
<br />JUL 1 6 2009 AS57SraNT s~.4T.~ REGiSTRA/2; ;'
<br />LINCOLN, NEBRASKA ~ O ~ ~ O ~ O ~ ~ MUM~~SER~V~CE'a ~L7~ ~A~(3 ~ t
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<br />STATE OF NEeFiASKA -DEPARTMENT ©F WEALTH AND HUMAN SERVIGES FINANCE Ahlf~ $U~fPApF~' ~ ~ ~ ~'
<br />CERTIFICATE OF DEATH `:' ~~~'~~~~:~~'%~
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<br />1. DECEDENT'S-NAME (First, Middle, Lest, Suffix) 2. SEX ~'J.'pATF~O'F'D~ATF~ (Mc"., Day,:`rr~
<br />~cksori Stewart March`5-.'.'~bOS _
<br />Audrev _
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<br />6. GATE OF BIRTH (MC., Day, Yr.)
<br />OAY
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<br />5
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-LaBt Birthday 5b. UNDER 1 YEAR
<br />(Yrg.) MOS. DAYS HOURS MINS.
<br />BuL`'£alo County, Nebraska 80 May 6,..1928
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />7 30 Bay ~ WOSPITAL: Q Inpatient QIL~E9: ^ Nursing Hvme/LTG ~HaspiCe Facility ""
<br />84. FACILITY•NAME (II not Inatitutlon, glue street and number) ^ ERlOutpatiant Q Decedant'aHvme
<br />St. Francis Skilled Caro ^ D04 ^ Other(Specity)
<br />8c. CITY OR TOWN OF DEATH (Include Zlp Code) ~ ed. COUNTY OF DEATH
<br />Grand Island 68803 _ Hall
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<br />eb.000NTY 9c. CITY OR TOWN
<br />9a. RESIpENCE~STATE
<br />Grand Island
<br />Nebraska
<br />_- -
<br />9d. STREET AND NUMBER 9e. APT. ND 91. ZIP CODE 9g. INSIDE CITY LIMITS
<br />= vas ^ NO
<br />903 Boll Boulevard _ 68801
<br />10s. MARI7ALSTATU3 A7 TIME OF DEATH ~Marrled ©Never Married 1gb. NAME OF SPOUSE (First, Middle, Lest, Sufllx) If wife, give maiden name.
<br />^ Married, bul6eparated ^ Widowed ^ Divorced ^ Unknown auren V . Stewart
<br />11. PATHER'S•NAME (First, Middle, Laat, Sufpx) 12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br />uth ~~~ Am1as
<br />._.
<br />Gui B. H®ndrickson
<br />13. EVER IN U.B. ARMED FORCES? Give dates of service if yes. 14a.INFORMANT-NAME 14b. RELATIONSHIP 70 DECEDENT
<br />(Yes, no, or unk.) No Lauren V . Stewart Husband _
<br />--
<br />15. METHOD OF DISPOSITION t6a.EHBALMER-SIGNATURE 18b. LICENSE N0. 16c. DATE (Mv., Day, Yr. )
<br />^Surial ^Donation nhalmed...~ _ _ _ .,,., March- 6 2009
<br />......
<br />CITY /TOWN STATE
<br />rr,,AA 18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />;y> - p~Cremativn ^ Entombment
<br />^Removal ^Other(Spacify) Central Nebraska Cremation Service, Gibbon, Nebraska
<br />_
<br />' 176. Zlp Cade
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City dr TOWn, State)
<br />"' K a9.ne ihxlneral H 3213.>I~ N Fron St_ Grand Island NE 68803
<br /> 1S PART I. Enter the gLgjn pf„Sy¢Nfl--diseases, Injuries, Or complications°ihat directly caused the death. 00 NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
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<br /> respiratory arrest, or vanirlcular fibrillallon without showing the etiology. b0 NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional lines if nad866ary. i
<br />a: ~ onset to death
<br />IMMEDIATE CAUSE:
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<br />IMMEDIATE CAUSE (Flnal (a) _
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<br />dlawaeorcandltlonraaulting DUE 70, ORASA NSEOUENCEDF: Onsettvtleath
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<br />Saquentlallyllatwndltlona,ll (b)
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<br />am/, leading toth~cauee lleted pUE 70, OR ASACON5EDUENCE OF: I oneel to death
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<br />. Entertha UNDERLYING CAUSE
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<br />the evanle reaultlnq In death) DUE TO, OR ASACDNSEDUENCE OF: I onset to
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<br />• 18. PART u. OTHER SIGNIFICANT CONOITIONS•Conditionscohtribute to the death but not resulting In the underlying cause given in PART I. ~19. WAS MEDICAL EXAMINER
<br /> ~J ~ OR CORONER CONTACTED?
<br />~/d•~~r/cr.."J~`"+ /v~~s~~a ~
<br />OYES NO
<br />.may( .. .._
<br />2g IF FEMALE: ~ 21a. MANNER OF DEATH 216. IF TRANSPpRTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />~Nalural ^ Homicide ^ OrlverlOperator
<br />~Notpregnantwithinpastyear ^ YES ~~NO
<br /> ^ Passenger
<br /> ^ Pregnant at time vl death ^ Accident^ Pending Investigation .. -.-
<br /> ^Pedeelrlan 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />Not pregnant, but pregnant within 42 days of death ^ Suicide ^ Could hat be determined
<br /> ^Dthar(5peClly) COMPLETECAU5EOFpEAT1i?
<br />CFI Nvt pregnant, but pregnant 43 days l0 t year before death
<br />
<br />~ ^Unknownil pregnant within the paelyear OYES ^ND
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<br />22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22C. PLACE OFINJURY-AI home, farm, street, factory, office building, Construction alts, etc. (SpeCily)
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<br />22tl.INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br /> [J VE5 CI NO
<br />~`' 22f. LOCATION DFINJURY-STREETBNUMBER, APT.NO, CfTY/fOWN STATE ZIP CODE
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<br />~ ~~ ~ 24a. DATE SIGNED (Mc., Day, Yr.) 24b.TIME OF DEATH
<br />23a. DATE OF DEATH (Mc., Day, Yr.) _ }
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<br />~ ~~ 23b.PATE31GNE0(Mo.,Dey,Yr.) 23c.TIMEOFDEATH ~~~ 24c.PRONOUNCEDDEAD(Mo.,Day,Yn) 24d.TIMEPRONOUNCEDpEAD
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<br />~a~ March 6, 2Q09 2:00 m ~p
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<br />24e. On the basis of examination and/or invesllgat
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<br />23d. Te the beat of my knowledge, dea occurred at the time, date and place
<br />~ p O the time, date and place and duo to the cause(s) Stated. (Signature and Title) ~
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<br />and due to the 9(6) st t gnaWre an
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<br /> 25. DIDTOBACC SE CON7RIBUTETO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? y~
<br />' ^ YES NO ^ PROBABLY ^ UNKNOWN ^ YES IO~ND Nat Applloable It 26a is NO C] YES Jdl NO _
<br /> 27.NAME,TITLEANDADDRE55DFCERTIFIER (PHYSICIAN,CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type orPrlnt)
<br /> Jane A McDonald, M.D. 80Q N Al h Grand Tsl-and NE 68803
<br /> 2Ba. REDISTRAR'SSIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />MAR 8 2009
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<br />HHS-61 11 /03 (55081)
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