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<br />STATE OF NEBRASKA `
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AIHL~HU~A SERVICES
<br />SYSTEM, /T CERT/PIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REG WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERV/CES SYSTEM, VITAL STAT/ST~s^~,~gl~~lH /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. "~ ' =
<br />~ _
<br />DATE OF /SSUANCE
<br />N,_,~ ~T =
<br />200 ~ ~r;t,.E~~.~OcER"
<br />LINCOLON, NEB $ S-KQ ~ ~ O ~ O O ~ ~ ~ ~ HEAL~#l Af~D ~MAN~~/CE3
<br />~I
<br />_ ~~:: _
<br />STATE OFNEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICES FIt~{51~GEANQ SIIF''~ORT /^+
<br />f_FGtTIFI!'ATF AC 11CATL,1 ~+ nr. ~ ~ Q ~ h
<br />~~
<br />
<br />1,• ,--... _. ___ _..-__._...~.
<br />, 1. DECEDENT'S•NAME (Flrsl, Middle, Last, SuHlx)
<br />2. SEX --_~,_y y c~ v v
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />`~'~ T.ho-maw M; rha-2 .y v
<br />eplber 10
<br />2005
<br />o
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5e. AGE•Last birthday --____
<br />5b. UNDER 1 YEAR 5c. UNDER i DAY _
<br />,
<br />.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS- DAYS HOURS MINS.
<br />;,' Sioux City, Iowa 63 April 28, 1942
<br />•
<br />"'
<br />F }~. 7.SOCIALSECURITYNUMBER
<br />~ Se. PLACE OF DEATH _ _
<br />..
<br />'~'~ 5 $ 5 - 4 8 - ~F 0 3 4 w. -.. - _;_A ~ H2S.P1796: ^ Inpatient Q~g ^ Nursing HomelLTC ^ Hospice Facility
<br /> •' eb. 1=ACICITY-PTAME (It not Institution, give street and number)
<br />
<br />FF i
<br />^ ERlOutpatiant ~ Decedent's Home
<br />G,
<br />5 0 9 Linden Avenue
<br />^
<br />^
<br />
<br />~
<br />~ an
<br />other (speolry)
<br />"'
<br />-; ~ 8c. CITY OR TOWN OF DEATH Include Zi Code
<br />; ( P 1
<br />ed. COUNTY OF DEATH
<br /> 'Grand Tsland 68801 Hall
<br /> T
<br />r; ~ ~?a.RE51DENCE-STATE 9b.000NN BaCITYORTOWN
<br />~~. Nebraska _ HaII Grand Island
<br /> 9d.STREETANDNUMBER 9e. APT. NO Bf.ZIPCODE gg.IN51DECITYLIMITS
<br />• 509 Linden Avenue 68801 ^ Yes ~ No
<br />
<br />~ 10a. MARITAL STATUS AT TIME OF DEATH Married ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) II wife, give maiden name.
<br />~'~
<br />,1 ^ Married, but separated Q Widowed ^ blvorced ~ Unknown
<br />` __ Primrose Albee __._.-
<br />~, 11. FATWER'S-NAME (First, Middle, Lest, Sulflx) 12. MOTWER'S-NAME (First, Middle, Maiden Surname)
<br /> Clair Conway Mari
<br />e
<br />Ruchala
<br /> __
<br />_
<br />_
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yes, no,
<br />or unk.) no
<br />Primrose Conway
<br />jn]1~
<br />e
<br />
<br />
<br />• ,
<br />_
<br />_
<br />_
<br />15. MBTWOD OF DISPOSITION 18e. E BALMER•SIG•A
<br />~.lu^""' TA~E 18b. LICENSENO. i6c. DATE (Mo., Day, Yr. )
<br />t~ eudal C.I Donation //.rL~~ 13 2 8 Nov . 15 ,
<br />2 0 0 5
<br />L
<br />R
<br /> _
<br />Y, C
<br />EMATORY pR gTHER LOCATION CITY /TOWN ~ STATE
<br />U Cremation ^ Entombment 16d. CEME R
<br />,r
<br />CJ Removal ^ Other (Specify)
<br />" Grand Island Czty Cemetery_ Grand Island, Nebraska
<br /> 17e. FUNERAL HpME NAME AND MAILING ADDRESS (Street, Clty orTVwn, State) 17b. Zip Code
<br /> A11 Faiths Funeral Home 2929 S. LoCUSt 5t. Grand Island NL 6 E~.1
<br /> s.a- ~. , . ~~ . ;~ ,.
<br />~~`} 18. PART I. En1ar the chain of events--dleeeses, injuries, or compllcatlons-•that directly caused the death. DO NOT enter terminal events such as cardiac arrest, ~ APPROXIMATE INTERVAL
<br /> ,
<br />~iC~^ I
<br />respiratory arrest, or ventricular fibrillation without showing iha etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilna. Add addltlonal lines If necessary. I
<br />- _ IMMEDIATE CAUSE: I onset to death
<br />I
<br /> (a) Coronary Occlusion ~ 'minutes
<br /> IMMEDIATECAUSE(Flnal
<br /> dlseaeeorconditlonresulting DUE TD, pW AS A CONSEQUENCE OF: '"
<br />I ansetlodaath
<br /> Indeath)
<br />I
<br />
<br />~) I
<br />8equenllally Ilet candltlvna, If
<br />
<br />-- eny,leadingtoihecauaellated DUE TO, ORASACONSEgUENCEOF: I onset to death
<br />onllnea.
<br /> Enter the UNDERLYING CAUSE I
<br />' _ (dleeaee or Injury thetinidated (c) I
<br />I
<br /> _
<br />_
<br />iheavenisrosultinglndeeth) DUETO,ORASACONSEOUENCBOF:
<br />th T
<br />onset to d
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<br />' 18. PART 11.OTHER SIGNIFICANT~CONDITIONS•Condltlons contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL. EXAMINER
<br /> OR CORONER CONTACTED?
<br />r~~' ~ YES ^ NO
<br />
<br />~ "
<br />,;~'"
<br />,. ~~. 20. IF FEMALE: 21 e. MANNER OF DEATH 21 b. IF TRANSPORTATION INJURY 21c.WASANAUTOPSYpERFORMED7
<br />Q Not pregnant within past year ~ Natural ^ Homicide (~ Drlverl0perator
<br />^Passenger ^ YEB X~NO
<br />^ Pregnant at lime of death ^ Accident^ Pending Investlgalion
<br />
<br />_~~;~ ^ Not pregnant, but pregnant within 42 days of death ~] Pedeatrlen 21d. WEREAUTOPSY FINDINGS AVAILABLETD
<br />^ Suicide GI Could not he determined
<br />
<br />~'
<br />~~ ^ Not pregnant, but pregnant 43 days to 1 year hefore death ^ Other (Specify) COMPLETE CAUSE OF DEATH?
<br />.
<br />'' ^ Unknown II pregnant within the past year ^ YES ~ ND
<br />E
<br />
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<br />' _ .. -~ _.. .-
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<br />ntl'•-c=%C ~ Y (~`*7^ ~ zzn• . PCALrE$F'TN9iJ~R -~iome'iarm, street lectory, olrlca building, conetrudlon aRe, etc. ($peclly)
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<br />'-~- ........_
<br />22d.INJURYATW
<br />pRK4 -.. _.... ... ._.. _....._.-
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br /> ^ YES ^ Np
<br />,,
<br /> 22f. LOCATION OF INJURY • STREET R NUM6ER, APT. N0. CfTY/TOWN STATE ZIP CODE
<br />
<br />~
<br />~ 23a. DATE OF DEATH (Mo., Dey, Yr.) a ~ 24 . DATE SIGNED (Mc., Day, Yr.) 24b.TIME OF DEATH
<br />~
<br />~~
<br />- ~~
<br />0100 m
<br />' _
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<br />-
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<br />_.
<br />23b
<br />DATE SIGNED (Mo
<br />De
<br />Yr
<br />) 23
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<br />y,
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<br />OF DEATH ~ ~ ~ 24v. PRpNOUNCED DEAD (Mo., Day, Yr.) 24d. TtMEPRONOUNCEDDEAD
<br />'
<br />' E
<br />0 m ° ~ a $ November 10, 2005 1400 m
<br />~ 0
<br />~
<br />-
<br />. m :~ 23d. To the hest of my knowledge, death occurred at the time, data and place
<br />u°Ci
<br />24e. On the basis of examin Lion andlor Investlgatlon, In my opinion death occurred at
<br />and due to the cause(s) stated. (Signature and Title) •
<br />p ih
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<br /> F ~ a t
<br />r~, tlate and p
<br />a nd due t he cause(s) staled. (Signature and Tltla)
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<br />- 25.pIDTObACCDUSECONTRIBUTETOTHEDEATH7 26a.NASORGANORTISSUEDONATIDNBEENCONSIDERED7 26h.WAS NSENTGRANTED?
<br />'
<br />YES NO ^ PROBABLY ^ UNK
<br />_ _ Y NOWN ^ YES ~ NO
<br />Nol Appllc
<br />a
<br />ble if 26a is NO ~..) YE5 C~ NO
<br />_ __ _ _
<br />_
<br />_
<br />27 NAME, TITLE AND ADDRESSpFCERTIFIER (PHYSICIAN,CORONER'SPHY5ICIAN OR COUNTY ATTORNEY! (Type or Print
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<br />ocust, Grand Island, NE
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<br />
<br />I 28a.REGISTRAR'SSlGNATURE
<br />~ 284. PATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> ~• NOV ~ ~ 2005
<br />
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