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1;, F.:
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEA f~,~ERIIICES; IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR ~Al{~~~Al~~f~ ,MEAL'TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FDf,~'V`~9~ ~ ;'~d*~~, A'
<br />DATE OF ISSUANCE L- ~.~ ~~
<br />t
<br />08/13/2009 ~~
<br />~ i:l~1EAtT p~HEA~.~H;ary~ a~-
<br />LINCOLN, NEBRASKA ' HI~M,QAl~,~6~i CE5 , ~. ~~ ~ ,,:+
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN $ERVI~ Sfi~+ - • ,~'~ ,.,,;; ~ 09 01743
<br />CERTIFICATE OF DEATH '` ~ , ~ J 9 ~,~'9F, `~" ..
<br />1. DECEDENT'S•NAME (First, Middle, Last, Suffix) 2. SEX 4 ~;„+ 8, gAS6.~F BATH (Mo., Day, Yr.)
<br />•~.
<br />Linda Belle Perkins Female ~ August 8, 2009
<br />4. CITY AND STATE OR TERRITORY, qR FOREIGN COUNTRY qF 81RTH Sa. AGE • LdSt 8lrthday b. UNDER 1 YEAR 5C. UNDER 1 DAY 8. DATE OF BIRTH (MO., Day, Yr.)
<br />(Y~•) MOS. DAYS HOURS MIN3. '
<br />Central City, Nebraska 63 March 4, 1946
<br />7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />505-54-3694 HOSPITAL ^ Inpatient OTHER ^ Nursing Home/LTC ^ Hoaplca Facility
<br />8b. FACILITY•NAME (If not Institution, give street and number) ©ERlOutpatlent ®OecedelH's Home
<br />4027 Scheel Rd ^ ooA ^ Other (Speclry)
<br />U
<br />~ ec. CITY OR TOWN OF DEATH (Include Zlp Code) 8d. COUNTY OF DEATH
<br />o Grand Island 68801 Hall
<br />9a. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
<br />z Nebraska Hall Grand Island
<br />~ 9d. STREET AND NUMBER e. APT. Nq. 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />4027 Scheel Rd 68801 ®YES ^ No
<br />~ 10a. MARITAL STATUS AT TIME OF DEATH ®Marrled ^ Never Manlad 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wHe, give maiden name
<br />m
<br />^ Married, but separated ^ Widowed ^ Divorced ©Unknown Charles Lloyd Perkins
<br />d
<br />11. FATHER'S•NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br />Lumier Kucera Erma VanPelt
<br />a 13. EVER IN U.S. ARMED FORCES? Give dates of service H Yas. 14a. INFORMANT•NAME 14b. RELATIONSHIP Tp DEGEpENT
<br />E
<br />$ (vas, No, or unk.) No Charles Llo d Perkins Husband
<br />15. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE 18b. LICENSE No. 18c. DATE (Mo., Day, Yr.)
<br />H ©Burlal ©Donatlon
<br />Not Embalmed August 10, 2009
<br />® Cremation ^ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br />^ Removal ^ Other (Specify)
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, State) 17b. Zip Code
<br />All Faiths Funeral Nome, 2929 5. Locust Street, Grand Island, Nebraska 88801
<br />AU E F DEATH ea instruct ons an exam es
<br />18. PART I. Enter the chain of events--dlseasea, InJurlea, or compllcatlona-that directly caused the death. DO NOT enter terminal awnta ouch as ardlac arroat, I APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without snowing the etiology. DO NOT A86REVIATE. Enter only one cause on a Ilne. Add additional Iinea IT necessary.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final al Respiratory Failure X24 Hours
<br />disease or cCnditlan reaulting
<br />in death) DUE TO, OR AS A CONSEQUENCE OF: Onset to death
<br />Sequentially Iin conditlona, If b) Metastatic Colon Cancer ; ~1 Year
<br />any, IBetling to the cause Iiatad
<br />on Ilne a. DUE Tq, qR AS A CONSEQUENCE pF: 7 onset to death
<br />Enter the UNOERLVING CAUSE C')
<br />(dlaeaw or InJury that Initiated
<br />the events reautting In death) DUE TO, pR A5 A CONSEQUENCE OF: onset to death
<br />usT d)
<br />78. PART II.OTHER SIGNIFICANT CONDITIONS•Conditlons contrlbuting to the death but not resulting in the underlying cause given in PART 1. 19. WAS MEDICAL EXAMINER
<br />OR CQRONER GONTAGTEg9
<br />d. ^YES ®NO
<br />w 20. IF FEMALE: 21a. MANNER OF DEATH 216. IF TRANSPOR7A710N INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />LL
<br />®Not pregnant wlthln past year ®Natural ^ HdmlCide ^ OHvar/Operator ^ YES ® NO
<br />V ~ Pregnant at time oT death ©ACCldent ^ Pending InVeatigatltln ^ Passenger
<br />© Not pregnant, but pregnant wlthln 42 days of death ^ Padssldan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />©Sulclde ^ Cduld ndt be determined TO COMPLETE CAUSE OF DEATH?
<br />© Not pregnant, but pregnant 43 days td 1 year before death ^ Other (Specify)
<br />©Unknown IT pregnant wlthln the past year ^ YES ^ NO
<br />a 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, office building, cpnstructlDn site, etc. (Specify)
<br />E
<br />a 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />O
<br />f' ^YES ^ NO
<br />22f. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITYlTOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) ~ 24a. DATE SIGNED (Mo., Pay, Yr.) 24b. TIME OF DEATM
<br />S ~ August 8, 2009 ~ ~
<br />~ H } 23b. DATE SIGNED (MO., Day, Yr.) Y3c. TIME OF DEATH g ~ ~ } 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />~ = Au ust 10, 2009 01:00 PM ~ N ` z
<br />_c° O 7tl. Td the beat oT my knowledge, death occurred at the lima, date and place ¢ ~ O
<br />w 34a. On the balls of axaminatlon andlor Invastlgatlon, In my opinion death ocCUrrod at
<br />°c and due to the Caueels) stated. (Signature and TItIa) ~ ~ p the lime, date and place and due t0 the Caueele) itatad. (Signature and TItIe)
<br />4 Jennifer L. Brown, MD ~ ~ o
<br />25. DID 708ACCp USE CON7RI8U7E Tq THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CDNSIDERED7 28b. WAS CONSENT GRANTED?
<br />^ YES ®NO ^ PROBABLY ^ UNKNOWN ©YES ®NO Not Applicable If 26a Is NO ^YES ^ NO
<br />I 1 N ype or tint
<br />Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />29a. REGISTRAR'S SIGNATURE 28b. DATE FILED 8Y REGISTRAR (Mo., Day, Yr.)
<br />August 11, 2009
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