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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 ORIG/NAL RECORD pN FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, V/TAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE a~' '
<br />q~c o s 2ao7 2o10oiss4 ~'~ R
<br />ASSISTl7~3~ ;
<br />LINCOLN, NEBRASKA HEALT~IDMA ~~
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<br />STATE pF NEf3FtASKA-- DEPARTMENT OF HEALTH AND HUMAN SEFIVIS,`ES ~I#q(~J~rW~~PQ ° ~q
<br />CERTIFICATE OF DEAT~1 ~ •, ~~a" :~~ ~ `i'
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<br />1. DECEDENTS•NAME (First _ ~_ W Middle, Lest, Suftlx) ',{,
<br />2'9&~, ^ , n~ _~ _. _
<br />1~7.pAS~OF~ATH ~(Mo., Day, Yr.)
<br /> Alberti Earl Srown ''!., },~e) ~~, 4V er 23, 2007
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Last Birthday 5b. UNDER 1 MBAR` ~xC
<br />5c~fOtvQE Y- ~ d$. DAT,EOF BIRTH (MO., pay, Yr.)
<br /> (Yrs.) MOS. pAYSt HOURS MI S. "
<br /> Roak Springs, ~yominq
<br />_ rv ~ 72 7w-uguati 16, 1935
<br /> 7.SOCIAL5ECURITYNUMBER Ba.PLACEOFDEATW
<br /> 505-34-8905 HOSPITAL: j~ Inpatient 4TkffB: ^NursingHoma/LTC ^HospiceFacility
<br />~`` ILI7.Y-NAME (If not_institu(ion, ~Ive street and number)
<br />• - » ~""'-'"" ~ ~
<br />^ ERlOutpetient ... _ ~ - L.l pecedeat's Home
<br /> $t. Er*11C1s MadiQal Cont~r
<br /> 0 Daq ^ Otner(Specify)
<br /> Sc. CITY OR TOWN OF DEATH (Include Zip Code) Bd. COUNTY OF DEATH
<br /> Grand Island 68803
<br />_ Hall
<br /> 9a.RE51DENCE-STATE 9b.CAUNIY 9c. CITY OR TOWN
<br /> N~braaka Hall Grand Island
<br /> 9d.STREETANDNUMBER 9e. APT. NO 9f. ZIPGODE 9g.IN51DECITYLIMITS
<br /> 2416 N Sheridan Av®. 68803 ~l Yes ^ No
<br /> tea. MARITAL STATUS ATTIME OF DEATH ]~ Mewled ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, plve maiden name.
<br /> ^ Married, bW separated ^ Widowed ^ Divorced ^ Unknown Evelyn A. Catch
<br /> 11. FATHER'S•NAME (First, Mlddla, Last, Suffix) 12. MOTHER'S-NAME (Flret, Middle, Maiden Surname)
<br /> Earl J. Brorm Leona (NMI) Chase
<br /> 13. EVER IN U.S. ARMED FORCES? Give dates of aervica if yes. 14a. INFORMANT-NAME 14b. RELATIONSHIR 70 bECEDENT
<br /> (Vas, n0, ar unk.) 06/26/1953-06/25/1956 Evelyn A. $rotr+rn Nife
<br /> 15. METHOD OF DISPOSITION iBe. EMBALMER-SIGNATURE 16b. LICENSE N0. 18c. DATE (Mo., Day, Yr. )
<br /> ^Burial ^Donanon (Not Embalmed) November 23, 2007
<br /> ~Cramation ^ Entombmeru 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY! TOWN STATE
<br /> ^Removel ^Other(Specify) Central Nebraska Cremation 8erviao, Gibbon, Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City brTown, State) 17b. ZIp Coda
<br /> irltaine Etitnaral Hama, 3213 m North Front St., Grand Island, NE 68803
<br /> 18. PART I. Enter the chain of events••diseasas, InJurles, or compllcations••that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
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<br /> respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Ilnea If necessary. I
<br /> IMMEDIATE CAUSE: [~~/ ~) .~5"',~~J~~J ///' I uonset~to Breath
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<br /> IMMEDIATE CAUSE(Flnel (a)
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<br /> dleeswacarMklonrosulting DUE T0, OR AS A CONSEQUENCE OF: I onset to death ~.
<br /> In death) I
<br /> Saquentlallyliatcondltiona,k (b) I
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<br />any,laedingtothecaueelleted DUE TO, ORA5ACONSEQUENCEOF: ~~~~ I onset to death T
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<br /> EnrerlheUNDERLYIN~CAUSE ~ I
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<br />thaeveMareaulttngtndaath) pUE T0, OR A3 A CONSEOUENCE OF: I onsatto deaf
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<br />~ 18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
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<br />OR CORONER CONTACTED?
<br />^ YES ~~NO
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<br /> 20. IF FEMALE: ~//\ 21e.MANNEROFDEATH 21 b. IF TRANSPORTATIONINJURY 21c.WASANAUTOPSYPERFORMED7
<br /> ^ Not pregnant within pesl year }-r Natural ^ Homicide ^ Driver/Operator
<br />^YE5 ~NO
<br /> ^ Pregnant el time of death ^ Accldent^ Pending Investigation
<br />^Pessenger
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<br />3:v " © Not pregnant, but pregnant within 42 days of death ^ Suicide ^ Could not ba determined ^ Pedestrian ~~~
<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br /> ^ Not re nant, but ra nant 43 da a to 1 ear before death
<br />P 9 P 9 Y Y ^ Other (Specily)
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<br />COMPLETECAU5EOFDEATH7
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<br />^ Unknown if pregnant within the past year ~~ /~
<br /> 22a. _DATEQf'_tN.IU*BY~{MQ.zOgy Yl,)--_--_.. h.:IMf 4F-INJURY 28o-. PLAC F~UJJU~Y-At home, tarm,.atresl, saFt4ry; ottice0ullding, construction site, etc. (Spedt}y)
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<br /> 22d.INJURYAT WORK? 22e. DESCRIBE HOW
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<br />Y OCCURRED
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<br />i ;ir~ 22f. LOCATION OF INJURY • STREET & NUMBER, APT. N0. Cm'lroWN STATE ZIP CODE
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<br />2416 N Sheridan Ave. Grand Island, Nebraska
<br />68803
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<br />23a. DATE OP EATH (M ., Day, Yr.) = 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIME DF DEATH
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<br />.~~ ~ y 23b. DATE SIGNE (MO., Day, Yr.) 23c.TIME OF DEATH ~ _ ~ 24c. PRONOUNCED DEAD (MO., Dey, Yr.) 24d. TIME PRONOUNCED DEAD
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<br />23d. To the st m knowledge, death occurred at the time, date and place ~ w m ~ 24e. On the basis of examination andlor investigation, in my opinion death occurred et
<br />en ue t eus )stated (Signature and Title) ~ ~ o ~ the time, date end place end due to the cause(s) stated. (Signature and Title)
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<br />~ 25.DIDTpBAC SECONTRIBU TO THEDEATH7 26a. HAS ORGAN ORTISSUE pONATION BEEN CONSIDERED? 26b. WA5 CONSENT GRANTED?
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<br />~5 ^ NO ^ PROBABLY ^ UNKNOWN ^ YES ~ Not Applicabl if 28a is NO Q YES ^ NO
<br /> 27. NAME, TITLE AND AppRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY A ORNEY) (Type or Print) ~ ~ _ ~, C
<br /> Travis Ha amen, M.D., 729 N Custer Ave., Grand Islan NE 68803
<br /> 28a. REGISTRAR'S SIGNATURE 2Bb. DATE F14Ep~Y REQIST~AR~Mo.OD~y, Yr.)
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