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2 o i o o i 4 ~ ~ $TAte ~t- NEBRASKA - pEPARTMENl' OF HEALTW AND HUMAN SERVICES ~~~~~~
<br />CERT I ATE OF 17EATM
<br /> 7. pECEPENT'8-NAME (Fbs6 Middle, LaSI, 9ulllx) 2. SEX 3. DATE tlF DEATH (Mq.,Day,YY.)
<br /> Jerry Lee Beekman Male March 16, 2009
<br /> 4. CITY AND STATE DR TERRITORY, OR FOREIDN COUNTRY OF BIRTH Sa. AtlE-Leaf Birthday 96. UNpER 1 YEAR 5c. UNDER 1 bAV 8. DATE OF BIRTH (Mo., bay, Vr.)
<br /> (Yrs.) MOB. DAYS HOURS MINE.
<br /> Grand Island, Nebraska 60 April 27, 1948
<br /> 7. SOCIAL SECURITY NUMDER Ba. PLACE pF DEATH
<br />~ 507-64-5090 HOSPITAL: Q Inpatient 971iE[t: ^ Nursing Home/LTC ^ Hvepics Facility
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<br />Bb. FACILITY-NAME (If opt IneNtutlgn, glue street and number)
<br />^ ER/Oulpatlant ^ Decadence Home
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<br />Nebraska Medical Center-University ©DOA ~ Olher(Bpaclly)
<br /> Bc, CITY OR TOWN DF pEA7H (Include ZIp Coda) Bd. COUNTY OF DEATH
<br />uJ Omaha 68198 l)ou las
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<br />~ 9a. RESIDENCE-STATE 96. COUNTY 9q. CITY OR TOWN
<br />', Nebraska Nall Grand Island
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<br />~ 9d. STREEY AND NUMBER 9e. APT. NO. 9t. XIP COPE 9g. INSIDE CITY LIMITS
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<br />•-1~i}3 ruby !-~venLle _. -_ -_
<br />68803
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<br />m 10a. MARITAL STATUS AT TIME OF DEATH ®Marrlad ^ Never Marrlad tpb. NAM@ OF SPOUSE (First, Middle, Laal, SuPix) II wife, glue maiden name.
<br /> ^Marrlad, but separated ©Wldowad ^ Divorced ^ Unknown Shirley Ann Brown
<br />G 11. FA7HER'B•NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
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<br />Willis Jacob Beekman
<br />Betty Louise Lac
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<br />lII 73. EVER IN U.$. ARMED FORCES? Give dales or service If Yaa. 14a. INFORMANT•NAME 1Ab. RELA710N$HIP TO bECEOENT
<br />~ (Yes, No, qr unk.) Yes 01/28/1988-12/15/1871 Shirt Ann Beekman Wift3
<br /> 15. METHOD OF DISPOSITION EMBALMER-91 ATURE 766. LICENSE ND. 18C- DATE (Mo., Day, Yr.)
<br /> ®asdel ©pnn+ttnu
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<br />March 20, 2009
<br /> ^~..,„adnp pE„ren,hm+nt
<br />©R+mw.l ~otherlepeelty) 1Bd. CEMETERY, CREMAT Y OR OTHER LOCATION CITY/rOWN . STATE
<br /> Broken f3Dw Cemetery 8rokan Bow Nebraska
<br /> 17a-FUNERAL HOME NAME AND MAILIND A~JDRESS (Street, Gity or 7gwn, Stale) ~ 776. Zlp Coda
<br /> Braman Mpl'tuary, 1702 N. 72nd Street, Omaha, Nebraska tpr 68114
<br /> Iversen Memorial Funeral Chapel, 305 N. 10th Avenue, Broken Bpw, Nebraska 68822
<br /> GAUSS OF DEATH (S®® instructions and examples)
<br /> 19. FART 1. Evl•r th+ ehsln o1 events . dl+e+ne+, Inlurbs, w mn,plleNlon~-Ihet dlmclly caunrd the dexlh. DO NOT solar Nrmin+l+Vrnl++uvh++a+rdl+c nre+l~
<br />APPROXIMATE INTERVAL
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<br />reeplr+lary errrar, ar wnlrkulpr phd11a11an Mrhvut +hawing the atlvlogy. DO NOT A6aReVIATE. enter only one ovus+orl+Iln+. Add +ddlUon+l Ilse+If neneeery.
<br /> IMMEDIATE CAUSE: ~ onset to death
<br /> IMMEDIATE CAUSE (Final r,, ( r~ ,
<br />disease or condition resulting a) ~c-( ~~ l
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<br />bUE TO, OR AS A CONSEPUENGE OF; , gneet tv death
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<br />any, leading la the cause listed
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<br /> qn Ilne a. DUE 70, OR AS A CpNSEQUENCE pF: t onset to deslh
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<br />f (disease qr Injury that inlllaled
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<br /> 18. PAR711.OTHER SIGNIFICANT CONDITIONS-Condltlgns contributing to the death but not resulting ht the underlying Cause given In PART 1, 79. WAS MEDICAL EXAMINER
<br /> OR CpRONER CONTACTEb7
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<br />~ ^ YE8 rt)j~ NO
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<br />W 2p. IF FEMALE: 21 a. MANNER OF DEAT1~1 276. IF TRANSPORTATION INJURY 21 c. WAS AN AUTOPSY PERFORME07
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<br />^ Not pregnant within past year
<br />~atural ^ Hvmlcide
<br />~] Driver/Operator
<br />^ YES NO
<br />W ^ Pregnant at Ilrne al death ^ Accident ^ Panding InvssNgagon ^ Pasaengar
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<br />^ Nol pregnant, but pregnant within d2 days q( death
<br />^ Suicide ^ Couid nal 6s determined
<br />^ Pedsaldan 21d, YYERE AUTOPSY FINOINtl9 AVAILABLE
<br />70 COMPLETE CAUSE DF DEATH?
<br />a ^ Nqt pregnant, but pregnant A3 days to 7 year before deal ^ Othvr (Specify) ^ YE9 ~NO
<br />~ ^Unknawn If pregnant within the pall year
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<br />E 22a. DATE OF INJURY (Mq., Day, Yr,) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, oHics 6ullding, construcgon aita, etc. (Beatify)
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<br />22d.INJURY AT WORK?
<br />22e. DESCRIBE HOW INJURY OCCURREp
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<br /> 22f. LOCATION OFINJURY - STREET &NUMDER, APT. NO. CITY/rOWN STATE ZJP CODE
<br /> 23a. PATE DF DEATH (Mn., bay, Yr,)
<br />2 Z 24e. DATE 51tiNEb (Mq., Day, Ye) 246. TIME OF DEATH
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<br /> ~ 236.OATS $IGNEb (Ma., D , Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAF (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
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<br /> 25.DID'j)'D8A000 l{91~Cf~I71R
<br />IBUTE TO'T D~'1'H'~¢• ~, 26a. HAS GROAN OR TISSUE DONATION BEEN CON9IDERED7 266. WA9 CONSENT ORANTE07
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<br />' ~,27: JJA~IE ITL~~ANp ApPRe53 OF,C TIFII~ (PW~SICIAN, CORONER'S PHY5ICIA OR COUNTY A ORN ) (Typo o Print)
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<br />:' 26a. RE 67RAR'$„31 266. DATE FIL@DBY REGISTRAR (Mo., bay, Yr.)
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<br />This certifies this document to be a true copy of an original record on file with Vital Statistics,.Douglas County
<br />Health Dept., Omaha, Nebraska. Certified copies must have a raised seal in the area to the left. Reproductions
<br />of this green certificate are not legal copies.
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<br />Date Issued: '~ 3 ~U~~ Registrar: ~~ ~~
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