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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF ~,E,~1'L-Tf%AN~HUI+?~N SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE~'BR.A,~C~ [~EPAR EN3" O~ HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSIrtC~RY~(~~'Z'`%IT_AL.f,7E~' ~,
<br />~`~
<br />DATE OF ISSUANCE '` ~~ ~', _ r ~~
<br />y • : STANLEY S: CQ4P~, ; ~f
<br />~~ ~ ~ ' ~- AI~A/y~'~AT~'R~~l.~TRAR
<br />R " D A ~ E~ HE,4,wTH AND
<br />LINCOLN, NEBRASKA it} ~~1 .HUMAN .5ERU'ICES' ~y> ~'
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<br />20~000~0~
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<br />STATE OFNEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICEa FI~~V~E xyP~~ilflPpQRt`
<br />f"FQTICIf ATC AC 11C Aru g. < ..~[) r1 /'1 /'1 n r~
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<br />1. DECEDENT'S•NAME (First, Meddle, Laat, Suffix) 2. SEX ~ ~3.9ATEOFDEATH (Mo..Oey,Vr.) ~~
<br />Gean Lorraine Po a Female Nov. 16, 2009
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Lest Birthday 5b. UNDER 7 YEAR 5c. UNDER 1 DAY ~ B.OATE OF BIRTH (Mo., Day. Yr.)
<br /> (Yrs.) MOS. 9AY$ HOURS MNJ3.
<br />Crookston, Minnesota 90 Nov. 24, 1918
<br />
<br />7. SOCIAL SECURITY NUMBER _
<br />Sa. PLACE OF DEATH
<br />470-OS-7146 HOSPITALS ^ Inpatient QmEg +~] NwswpHornell-TG ^HoepiceFacillty
<br />Bb. FACILITY•NAME (II not Inetltution, give alreet end number)
<br /> ^ ER(Outpatlent ^ pecedent's Home
<br />Tiffan 5 uare Care Center ^ 904 ^Other(5peclry)
<br />8C. CITY OR TOWN OF pEATH (Include Zlp Cade) Bd. COUNTY OF pEATH
<br />Grand Island, NE. 68803 Ha11
<br />9e. RESIDENCE•STATE 9b. COUNTY 9c, CITY OR TOWN
<br />Grand Taland
<br />_ Hal].
<br />~ Grand Island
<br />9d. STREETANO NUMBf;R
<br />9e. APT. NO 91. ZIP CODE 9g. INSIDE CITY LIMITS
<br />249 Michd.gan Ave _ 68803
<br />Xl YES • ^ No
<br />_
<br />10e. MARITAL STATUS A7 TIME OF DEATH ^Marrled ^ Never Marrled tOb. NAME OF SPOUSE (First, Middle, Last, 5ufllx) II wile, give maiden name. ~.
<br />^Marrled, but separated ~Wldowed ^Divvrced ^Unknown Kenneth Pope (Deceased)
<br />_.
<br />
<br />11. FATHER'S-NAME (FIre6 Middle, Lash Sulflx) 12. MOTH
<br />~~ ER'S•NAME (First, Meddle, Maiden Surname)
<br />George Olie Carlson Genett
<br />A. Sunderland
<br />- -...w.
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<br />._.
<br />~~ 13. EVER IN U.S. ARMED FORCES? Glve dates vl service If yes. 14a.INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />IVee, nv, or unk.) No Nancy Weeks Daughter
<br />15. METHOD OF DISPOSITION 18a. EMBALMER•SIGNATURE 18b. LICENSE N0. Ise. OATS (Mo., Oay, Yr. )
<br />^Burlal ^Doneticn NOt Emblamed _ __
<br />NOV. 1], 2009
<br />_
<br />Cremation ^ Entombment 18d. CEMETERY, CREMATORY OR gTHER LOCATION CITY I TOWN ~ ~ ~5TATE
<br />QRemvval ^Dmar(speafy) Weatlawn Crematory Grand Taland NE.
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clly or Tawn, Slate) 176. Zlp Code
<br />F Livingston-Sondermann Funeral Home 601 N. Webb Road Grand Island, NE. 68$03
<br />tP, PART I. Enter the ghglr101 BVBnIg--diseases, injwlea, orcomplications--that directly ceu9ed the death. DO NDT an{er terminal evYnta ouch as Cal'diec erroet, APPROXIMATE INTERVAL
<br />I
<br />respiratory arrest, or ventrlCUler fl6rillalicn without ahvwing the eliolagy. DO NDT ABBREVIATE. Enter only One Cause vn a line. Add additional line9 if necessary. I
<br />~y IMMEDIATE CAUSE:
<br />~ On9e110 death
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<br />' IMMEDIATE CAUSE(Flnal
<br />dleaaeeorCVndlavn rewlang ~ DUE T0, OR A5 A CONSE9UENCE OF: ~ 'ir onset tC death
<br />k1 death)
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<br />~ ~ W ~ \ ~~
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<br />Saqusmlally Ilat cvndltevna, II (b) ~~~~ ~ L C ~ V ~~
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<br />any, leading tv the caun elated pUE TO, OR ASACONSEgUENCE OF: ~ I onset to death
<br />vn 8n• s.
<br />EMertM UNDERLYINp CAUSE I
<br />IdlteeHarlnlurythatlnltleted (C) I
<br />the eVeM/resuNing In death) .... --~.-~ ..J
<br />
<br />
<br />DUE T0, OR A5 A CONSEDUENCE OF:
<br />angel lC death
<br />r LAST
<br />(d) I
<br />B. PARTILOTHERSIGNIFICANTCON TIONS-Condltlo~cgarlbutingt the deathbut~tresultln
<br />g In the undol~1ying cause given in PART I, ~. WAS MEDICAL EXAMINER
<br />_ .L ~
<br />~T ~ OR CORONER CONTACTED?
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<br />X20. IF FEMALE: 21a.MANNERgFDEATH 21b.IFTRANSPORTgTIONINJURY ic.WA3ANAUTOPSVPERFORMED?
<br />~NCt pregnant Within pest year ~Nelural ^ Homicide ^ Oriverl0perator
<br />^ Pregnant et time of death ^ Accitlent^ Pending Inve9tlgatlon ^ Passenger ^ YES ~NO
<br />Q Nat pregnant, but pregnant within 42 days of death C] Pedestrian ttl. WERE AUTOPSY FINpINGS AVAILABLE To
<br />^ Suicide U Could not be determined
<br />^ Npt pregnant, but pregnant 43 days to 1 year before death ^ Other (Specify) COMPLETE CAUSE OF DEATHI a
<br />^ Unknown II pregnant within the poet year ._.,,•„••,_ ^ VES ^ NO
<br />22e. OATS OF INJURY (Mo., Dey, Vr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, term, street, factory, oglce building, construction ails, eta. (Specify)
<br />m
<br />22d.INJURYATWORK?
<br />^ YES ^ NO 22e.pE5CRIBEHOWINJURYD000RRED
<br />22f. LOCATION OFINJURY-STREET8NUM8ER, APT.NO. CITY/fOWN m S1ATE ZIP COOS
<br />23a. DATE OF bEATH (Mo., Dey, Yr.) z
<br />24e. DATE SIGNED (Mo., Day, Yr.)y 246. TIMEOF DEATH
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<br />yr ~Jb.OATESIGNED(Mo.,Day,Vr, 23C.TIMEOFOEATH ~~ 24C.PRONOUNCEDOEAO(MO.,Day.Vr.) 24tl.TIMEPRONOUNCEOOSAD
<br />~77
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<br />FFith \1-\~' C7
<br />2:45 p.m ~p`z~z m
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<br />3d. To the beat of my knowledge, deatlGopeu ed al the time, date and piece
<br />24e. On the b0sis of examination and/or Inv6atlgallon, in my opinion death occurred at
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<br />SEeuB St (SI at re end Title) •
<br />~ V the lime, date and place and due to the cause(s) slated. (Signature and Title)
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<br />5. DIOT08AC I TE E DEATH? . 8a. HA RGAN qR TISSUE DONATION BEEN CONSIpERED?
<br />~ 266. WAS CONSENT GRANTED?
<br />^ YES NO ^ PR_OBABLY ^ UNKNOWN ^ YES
<br />O
<br />~ Nol Applicable i1 2Sa is NO ^ YES NO
<br />27. NAME, TIT
<br />b ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Steven Husen 2116 W. Faidle Ave. Grand TEtland, NE. 68803 (Physician)
<br />28e. REGISTRAR'S SIGNATURE 25b. DATE FILED BY REGISTR R Mo., Oa , Yr.
<br />NQV ~ ~ 2~0~
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<br />HHS-61 11 /03 (55061)
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