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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH~4ND HL~MAII--SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD pN FILE WITH THE NEBRASKA DERARTME~T OF~HEALTFI AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL l~C014Cf5: • •~
<br />DATE OF ISSUANCE ~ ~~r ;. .
<br />au~ 0 7 2009 SrAn~c~vS. ~o,~1PER .- . ;
<br />q ~f As.~ISrANT;~,~~,~~,~~c~t~sraAr~ ~~;.
<br />LINCOLN, NEBRASKA ~ O 0 "' O ~ O ~ HUMANSEf~V,ICES EALTH AND
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<br />STAtE pf=NEBRASKA- DEPARTMENT OF HEALTH ANp HUMAN SERVICES FINANCE AND SUPPp~•g `~ ~~ ~+
<br />CERTIFICATE OF DEATH C.~ a
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<br /> 1. DECEDENT'S•NAME (FIra6 ________ Middle, Last, ~~ Suffix) 2. SEX 3, DATE OF DEATH (Mo., Day, Yr.)
<br /> .. Llnyd Fr-an ~ ~
<br /> 4. CITY ANO STATE OR Tl=RRITORV, OR FOREIGN COUNTRY OF BIRTH 59. AGE-Last 8irthdey 5b. UNDER 1 YEAR 5C. UNDER 1 DAY 8. BATE OF BIRTH (MO., Day, Yr.)
<br /> (Yrs.) MOS. bAVS HOURS MINS.
<br /> Wood River, NE 6
<br />6 A ri12S 1943
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<br />7. SOCIAL SECURITY NUMBER r
<br />-,_. - _. _ __
<br />a. PLACE OF bEgTl~.
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<br />SOS-54-4352 }~,
<br />k1R9P1IAL: *31 Inpatient Q i]}~R CI Nursing HomeILTC ^ Hospice Facility
<br /> 86. FACI4LTY NeM!` (It: nat.lpslityilpn..4Lve ilre6t and nuwber) ~ - ~] ER7qulprttknt ^ Dacadwd'eHome
<br /> St. Francis Medical Center ^ an ^ gmer (speary) _
<br /> 8c. CITY OR TOWN OF DEATH (Include Zip Cade) Btl. COUNTY OF DEATH
<br /> Grand Island 68$03 Ball
<br />_ Ba.RE61DENCE•STATE 9b.000NTY` BC.CITVORTOWN ~~
<br />i - Nebraska Hamilton
<br />~~ Aurora
<br /> 9d. STREETANDNUMBER Be. APT. NO 91. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 808 14th Street 68$1$ ~CYE5 ^ NO
<br /> 10a. MARITAL STATUS AT TIME OF DEATH ~1 fJMrrlad ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) It wife, glue maiden name. -
<br /> ^ Married, but 8aparatad ^ Widowed L:I Divorced ^ Unknown Janice Fenster Zebr •
<br />- 11. FATHER'S-NAME (First, Middle, Lest, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br />- .3 Karl E Opp Colene Anderson
<br />- 13. EVER IN 116. ARMED FORCES? Give dates of aervlce If yes. 14a. INFORMANT-NAME ~N ~ 14b. RELATIONSHIP TO DECEDENT
<br /> (Yes, no. Cr unk.)NO Ja Op WiFe
<br /> 15. METHOD OF DISPOSITION a. E 18ALMER•SIGNAT R ' 186. LICENSE N0. ~~~ i6c. BATE (Mo., Day, Yr. )
<br />~" ~ dyrial ^ Donation T ~'g Z~~ July 20, 2009
<br /> ^Cremation ^Entombment d.C MET ,CRE 0 0 ATION CITYlTOWN STATS
<br /> ^Removal ^otner(spe~ny) Aurora Cemetery Aurora Nebraska
<br /> 17a. FUNERAL HOME NAME ANb MAILING AbbRE55 (Street, Clty orTown, Stara) ~~ 17b. Zlp Cade
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<br />Hi b -McQuiston Mortua ,1404 L Street, Aurora, NE, 68818
<br /> 1& PART I. Enter the ~gjp,yj, avenJ&••dlseases, infurlea, or CCmpliCations--That directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
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<br />respiratory arreaL tlr ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add eddlllonel lines If necessary. I
<br /> IMMEDIATE CAUSE: I onset to death
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<br />- dlaea9eawndmvn rsaunlnB OUE TO, OR ASACONSEOUENCE OF: i onset tv tleeth
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<br />DUE 70, OR AS A CONSEgUENCE OF' ~ I onset to death
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<br />DUE TO,OR ASACONSEGUENCE OF:
<br />I onset to death
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<br />v 18. PART IL OTHER SIGNIFICANT CONDITIONS•CondlBona Contributing to the death but not reaultlng In the underlying Cause given in PART I. 79. WAS MEDICAL EXAMINER
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<br />OR CDRONBR CONTACTED?
<br />^ YES 0
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<br /> 2t).IFFEMALE:
<br />21a.,lAANNEROFDEATH 21d.IFTRANSPORTATIONINJURY 21c.WA5ANAUTOPSYPERFO MED7
<br /> U Not pregnant wlthln peat year Natural ^ Homicide ^ DriverlOperator
<br />^ YES
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<br />^Pasaenger
<br />^ Pregnant al lime of death ^ Accident^ Panding Invealigatltln
<br />+ ~ ~ ^ Not re nant, but re nant wlthln 42 da s of death ^ Pedeatdan
<br />p 9 P g y ^ Suicide ^ Could hat be determined 21 d. WERE AUTDPSY FINDINGS AVAILABLE TO
<br /> ^ NoPpregnan6 but pregnant 43 days to 1 year before death ^ Other (Specify) COMPLETE CAUSE OF DEATH?
<br />~: ^ Unknown if pregnant wlthln the past year _,•Y, ^ YES ^ NO
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<br /> 22e. BATE OF INJURY (Mo„ Dey, Vc) 22b. TIME OF INJURY 22C. PLACE OFINJURY-At home, farm, street, factory, Cfllca building, construction site, etc. (Specify)
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<br /> 22d.INJURYATWORK7 22e.bE5CR~8EHOWINJURY000URRSD
<br />~~,~ U YES~O
<br /> 221. LOCATION pF INJURY • STREET & NUMBER, APT. NO, CITYRpWN STATE ZIP CODE
<br /> 23e. D~uOF DEAT1 ~ ., Oay
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<br />(Mo., Da , Yc) 246.TIME _
<br />24a. DATE SS
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<br />y 236.OgTE SIGNED (Mv., Oey, Yc) 23c.TIME OFOEATH ~'_~ 24c.PRONOUNCEp pEA (MD., Day,Yr.) 24d. TIME PRONOUNCED DEAD
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<br />li ~ 2de. On the ba619 Of axemination andlor investigation, in my opinion death occurred at
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<br />the time, data and place and due to the cause(s) staled. (Signature and Title)
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<br /> 25.bIOTOBA000U5ECONTRIBUTE70THEDEA7H? 28a.HASORGANORTISSUEbDNATI0N8EENCON5IDERED? 26b.WA5CONSENTGRAN7Eb?
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<br /> 5 ^ NO ^ PROBABLY ^ UNKN N
<br />~ ^ YES 0 Nat Applicable If 26a i9 NO ^ YES ^ NO
<br /> 22
<br />ITLEANbAbbRESSOFCERTIFIER (PHYSICIAN,CORONER'SPHYSICIANOR000NTYATT NEY) (Type orPrlnt)
<br /> Sitki Copur, M.D- 815 N. Orleans Drive Grand Island, Nebraska 68803
<br /> 2Ba. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> d. ~u~ 2 7 Zoos
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<br />HHS-61 11/03 (55061)
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