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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTh~!~~WHICH IS
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<br />THE LEGAL bEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE _ _
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<br />LINCOLN, NEBRASKA H~IIL~#1 AND tIIJ~VIAIV•~EITVI~~S
<br />STATE OF NHBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FJM1S'~JPP ~ p C
<br />CERTIFICATE OF DEATH = `~~ ~ 5 8 5 5
<br />1. pECEDENT'S•NAME (First, Mlddle, Last, Suffix) 2. SEX 9. DATE OFpEA7H(Mv.,Day,Yr.)
<br />Tressia Irene Ashmore Female May 22, 2007
<br />4. CITY AND STATE OR TERRITORY, pR FOREIGN COUNTRY OF BIRTH 5a. AGE-Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Pay, Yr.)
<br />Benedict, Nebraska (Yrs.) 96 Mos. PAYS Houas MINS. June 25, 1910
<br />7. SOCIAL SECURITY NUMBER ~ Bs. PLACE OF DEATH
<br />507-78-8517 HOSPITAL: ^Inpatient jB: ~NursingHome/LTC ^HosplceFaclllty
<br />8b. FACILITY-NAME (If not Institution, give street and number)
<br />^ ER/Outpatient ^ pecedcnl's Home
<br />Tiffany Square Care Center
<br /> 0 pG4 ^ Other (Specify)
<br />Sc. CITY DR TOWN OF DEATH (Include Zlp Code) Bd. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />Ba. RESIDENCE-STATE Bb. COUNTY 9c. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />9d. STREETANDNUMBER 9e. APT. NO Bf. ZIP CODE 9g. INSIDE CITY LIMITS
<br />2114 N. Huston, 68803 ~1 rte ^ No
<br />10a. MARITAL STATUS ATTIME OF pEATH ~ Married ^ Never Married lob. NAME OF SPOUSE (Flret, Mlddle, Last, Suffix) If wife, give maiden name.
<br />^ Married, but separated ^ Widowed ^ plvarced ^ Unknown Wayne Ashmore
<br />11. FATHER'S•NAME (Flrsl, Mlddle, Lest, Suffix) 12. MOTHER'S-NAME (Flrat, Middle, Maiden Surname)
<br />Earl Ramsey Sarah Parker
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<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. 14a.INFpRMANT•NAME 146. RELATIONSHIP TO DECEDENT
<br />(res,no,orunk.) No Wayne Ashmore Husband
<br />15. METHOD OF DISPOSITION 18e. E BALMER-SIGNAT~lRE. , i6b. LICENSE N0. 16c, PATE (Ma., Day, Yr. )
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<br />' May 24
<br />2007
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<br />^ Cremation ^ Entombment t6d. pEMET Y, CREMATORY R OTHER LOCATION CITY /TOWN STATE
<br />^Removal OOther(Spaclfy) Westlawn Memorial Fark Cemetery Grand Island, NE
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty orTown, State) 77b. Zip Code
<br />Apfel Funeral Hame, 1123 West Second, Grand Island, NE. 68801
<br />18. PART I. Enter the cheln of events-•disaases, injuries, or cvmplicativns•-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, l APPROXIMATE INTERVAL
<br />resplretary arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause an a Ilne. Add additional lines it necessary. l
<br />IMMEDIATE CAUSE: l onset to death
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<br />IMMEDIATECAU8E(Flnel
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<br />dlaweearcvndklonreeultlng DUE TO, ORASACONSEOUENCEOF: I onset to death
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<br />Sequentleltyltatcdndltlona,if (b)
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<br />amy,leadtnglathecauselleted pUETO,ORASACON5E0UENCEOF: I onsettOdeath
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<br />Fsterthe UNDERLYING CAUSE
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<br />theevenbresul8nglndeath) DUE T0, OR A5 A CONSEQUENCE pF: I onset tc death
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<br />18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contrlbutlng to the death but not resulting In the underlying cause given in PART I. 1B. WA3 MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
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<br />1~~-C~K~ ~.J~ l~~QQ~ ~~'1M OQFL ~~.Y ^ YES ^ NO
<br />20. IF FEMALE: 27a.MANNEROFDEATH 21 b.IFTRANSPORTATIONINJURY 21c.WASANAUTOPSYPERFORMED7
<br />[Jot pregnant wlthln peat year
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<br />G a~Natural ^ Homicide
<br />'• Q Driverl0perator
<br />^ YES ~NO
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<br />Pregnant et time of death ^ Accidenl^ Pending Investigation ^Passenger
<br />^ Not pregnant, but pregnant within 42 days of death
<br />^ Suicide ^ Cvuld not be determined ^ Pedestrian 21d. WERE AUTOPSY FINpINGS AVAILABLE TO
<br />^ Not pregnant, but pregnant 43 days to 1 year belora death ^ Other (Specify) COMPLETE CAUSE OF DEATH?
<br />^ UnKnownifpregnantwithinthepastyeer ^ YES ~NO
<br />~;.p9I~OFINJURY..(Mo-,.Dy~,YC) ~ 22p..I1ldE0E.INJIIRY_
<br />m .PLACE OEaAI_URVJ~,te,.faun,Hreat;aaGwy,.sftlce-buHding,cseatruuteea-aile,atc.(Speciiy)_.._.
<br />22d.INJURYATW
<br />ORK7 22e. DESCRIBE HOW INJURY pCCURRED
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<br />22f.LpCATIONOFINJURY-STREET&NUMBER,APT. NO. CfTY/TpWN STATE ZIPCODE
<br /> 23a. DATE of DEATH (Mo., Dey, Yr.) _ } 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIME OF pEATH
<br />~a MAX 22, 2007 ~~~ m
<br />~, _ ~ 236. DATE SIGNED (Mo., Day, Yr.) 23c.71ME OF DEATH ~ ~ ~ 24c. PRONOUNCED DEAD (Mv., Day,Yr.) 24d.TIME PRONOUNCED DEAD
<br />Eaz MAY 23, 2007 2:20 Am paZ m
<br />~ c o 23d. Tv the best of my knowledge, death occurred el the time, data end place w ~ O 24e. On the basis of examination endlor Inveatlgatlon, In my opinion death occu«ad at
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<br />the time, data end place and due to the cause(s) stated. (
<br />and due to the cause(s) st fed. (Slgna ure end Title)
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<br />25.DIDTOSA000USECONT TETOTHEDEA7H? 28a.HA50RGANORTI55UEDONATIONBEENCONSIDERED? 266.WA5CONSENTGRANTED7
<br />[,~ YES NO ^ PROBABLY ^ UNKNOWN ^ YES NO Not Applicable if 26a is NO ^VES ^ NO
<br />27. NAME,TITL AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN ORCOUN ATTORNEY) (Type orPrlnq
<br />Dou las Herbek M.D. 2444 W. Faidley Ave., Grand Island, NE. 68803
<br />28a. REGISTRAR'S SIpNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yc)
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