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STATE"OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTht,~'~ Ul~1,~1'd''~~RVIC~S, IT CERTIFIES
<br />THE BELpW Tp BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASdCA ~~p,~~$~MLkN~ OE (-1~i4LTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPpSITORY FOR -I~'T~ R ~ ~ ~,-, ' ,r .
<br />" ~., r ~ ~'
<br />DATE OF ISSUANCE
<br />~~~
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<br />2 010 010 5 7 STALVLEY s E ~ ,, ; :.~
<br />11 /19/2009 ASs~7,4M~~trSTR,AR''
<br />DEQA~TMEI\l7' CAF HEALT"M ANI~
<br />LINCOLN, NEBRASKA HUM.~f SEj~y7('>w~ M „
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVPCrES c' ,~' ~,~~ t~ FA, ~,,"~`1 ~, ~~ " "
<br />CERTIFICATE OF DEATH • ~ , "' ~ :,,; ; " " ~ ~ " 09 02610
<br /> 1. DECEDENT'S-NAME (First Middle, Last, Sufflx) 2. SEX 9 3, /ATE pF. DEATH (Mo., Day, Yr.)
<br /> Ilene Jq ce Pletcher Female ~ Ni7V~mber 8, 2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 qAY B. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs•) MOS. PAYS HOURS MINS.
<br /> Lincoln, Nebraska 81 February 21, 1928
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE pF DEATH
<br /> 507-28-9032 HOSPITAL ®Inpatlent OTHER ©Nursing Home/LTC ^ Hospice Facility
<br /> 86. FACILITY•NAME (If not Institution, glue street and number) ^ ERlOutpatlent ^ Decedents Home
<br />V Saint FranGiB MedlCal Center ._ _ ^ DOA ^ Other (Specify)
<br /> 8c. CI'T'Y OR TOWN OF DEATH pncluda Zip Code) 8d. COUNTY OF DEATH
<br />a Grand Island 68803 Hall
<br /> 9a. RESIDENCESTATE 9b. COUNTY ec. CITY OR TOWN
<br />~ Nebraska Hall Grand Island
<br />~ 9d. STREET AND NUMBER 9e. APT. NO. 9f. ZIP CODE 9g, INSIDE CITY LIMITS
<br />,,, 2805 Circle Drive 68801 ®ves ^ No
<br />~ 10a. MARITAL, STATUS AT TIME OF DEATH ®Marrled ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Sufflx) If wife, glue maiden name
<br />:~ ©Married, but separated ^ Widowed ^ Divorced ^ Unknown Eugene Pletcher
<br /> 11, FATHER'S-NAME (First, Middle, Last, Sufflx- 12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br /> Clifford Bishop Bertha Mong
<br />~•
<br />E 18. EVER IN U.S. ARMED FORCES? Glve dates of service If Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ (Yes, No, or unk.) No Gene Pletcher Husband
<br />Q1 15. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />f~- ®Burial ^ Danatlon
<br />Daniel D Naranjo
<br />1071
<br />November 12, 2009
<br /> ^ Cremation ^ Entombment
<br />
<br />^ Removal ^ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY! TOWN STATE
<br /> Hillside Cemetery North Loup Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Gity or Town, State) 17b. Zlp Code
<br /> All Faiths Funeral Htame, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> A ea instructions and exam les
<br /> 1e. PART I. Enter the chain of eventa• •diaaasea, Inlurlea, or compllntlona-that directly cauwd the death. DO NOT enter terminal eventa such as cardiac arrest, ; APPROXIMATE INTERVAL
<br /> rosplrotory arrest, or vemncular fibrillation without showing the atlDlogy. b0 NOT A66REVIATE. Enter only One cause on a line. Add addltlCnal Ilnas If naCaaaary.
<br /> IMMEDIATE CAUSE: ~ onset to death
<br /> IMMEbIATE CAUSE (Final a) Subdural Hematoma ;Less Than 24 Hours
<br /> disease or candltlon resulting
<br /> in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> aequsmlally Ilat contlitiotn, If b)
<br /> any, bading to tba cauw listed
<br /> on Ilna a.
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAl13E C)
<br /> (disease or Injury that Initlatad
<br /> the eventa restating In death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />LAST
<br /> d)
<br /> 18. PART I1. pTHER SIGNIFICANT CONDITIONS•Conditlona contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> Pancreatic Cancer, Coronary Artery Disease, Atrial Fibrillation OR CORONER CONTACTED?
<br />a
<br />W ©YES ®Np
<br /> D, IF FEMALE: 21a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> ^ Not pregnant within past year ^ Natural ^ Homicide ^ brlverlOperotar
<br />
<br />~ ^ ~.ES ® NO
<br />^Prognant at time of death ®ACCitlant ^ Panding Investigation ^ Passenger
<br />T
<br />~ ^ Not Prognant, but pregnant within a2 tlays of death ^ guicide ©Could npt ba determined ^ Pedestrian 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br /> ^ Nol pregnant, but Prognant 43 days l0 1 year before death ^ Other (Specify) TO COMPLETE CAUSE OF DEATH?
<br /> ^ Unknown I(pregnaM within the past year ^ YES ^ NO
<br />~ 22a. GATE OF INJURY (Mo., Day, Yr,) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction alts, etc. (Specify)
<br />8 November 6, 2009 Unknown Home
<br /> 22d. INJURY AT WORKS 22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />^ YES ®NO Fell at home
<br /> 22f. LOCATION OF INJURY -STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br /> 2805 Circle Drive, Grand Island Nebraska 68801
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr:) 246. TIME OFDEATH
<br /> a ~ November 8, 2009 Y
<br />a ~
<br /> ~ ~ Y 23b. DATE SIGNED (MO., Day, Yr.) 23c. TIME OF DEATH
<br />~' ~ ~
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
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<br />E November 12, 2009 03:50 PM a i
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<br />S 9d. To the best of my knowledge, death occurred at the time, date and place
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<br />$ ~ Y4a. On the basis of examination andlor Inyettipetibn, In my opinion death occurred at
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<br />e(s) state
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<br />~ the time, data and place and due to the cause(s) stated, (Signaturo and Tltla)
<br /> ~ Jennifer L. Brown, MD & ~
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 266. WAS CONSENT GRANTED9
<br /> ^ YES ®NO ^ PROBABLY ^ UNKNOWN ^YES ®NO Not Applicable if 26a is NO ^YES ^ NO
<br /> AN DDR Y I I R ype or Print)
<br /> Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> November 13, 2D09
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