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STATE OF NEBRASKA ~-=--~,~_ '~- ,
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL ~! ,qND ~.~$~'w2 R'VI ~„ ~~T CE{ZTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR~(A ~~~~~~ ~~ H AIVD .
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOk ' i'T.Qr' ~ t7 ` ,rx ~ @ ~~
<br />DATE OF ISSUANCE i~/~~ ~rN' ~ ;,~
<br />03/05/2010 ~ ~ 1`~`~ ~'~ ~ ~ Ass ~L ~roT sooPER ,
<br />~~ ~7~ ~ /
<br />~ I~ ",„ ~.
<br />DEP,+~R~1~NT~'F)I:lEA1l-~,911)Gl: as
<br />LINCOLN, NEBRASKA HUN~i4/V'~~RVICErr I,. ~'
<br />sra,Te of r@eewnsK CERTIFICATEFOF DEATHHUMAN sERVI~~s x,„ ~~ Af C off,{ /-~~.~., ~ ~,~~~ 00574
<br /> 1. DECEDENT'$•NAME (First, Middle, Last, Suffix) 2. SEX (tr {DATt3 QF DF•~4TH D., Day, Yr.)
<br /> Heather L n Gideon Female '°' ~ Febtu ry..~7~010
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF 91RTH Sa. AGE -Last 9lrthday b. UNDER 1 YEAR Sc. UNDER /DAY 8. DATE OF BIR H (Mo., Day, Yr.)
<br /> (Yrs.) MOS. PAYS HOURS MINE.
<br /> LinGPln, Nebraska 35 June 21, 1974
<br /> 7. SOCIAL SEGURITY NUMBER Ba. PLACE OF DEATH
<br /> 506-04-3292 H PITA ©Inpatlent OTHER ^ Nursing Home/LTC ^ Hospice Facility
<br /> eb. FACILITY•NAME (If not Institution, grva street and number) [] ERlputpatient ®DacadenCa Home
<br />K
<br />A
<br />U 16006 West Wood River Road ^ DDA ^ Other (Specify)
<br />~ 8c. CITY OR TOWN OF DEATH (Include Zip Gode) 8d. COUNTY OF DEATH
<br />5 Wood River 68883 Hall
<br />J 9a. RESIDENCE•STATE 84. COUNTY 8c. CITY OR TOWN
<br />z
<br />Nebraska
<br />Hall
<br />Wood River
<br />LL 9d. STREET AND NUMBER e. APT. NO. 8f, ZIP CODE 9g. INSIDE GITY LIMITS
<br /> 16006 West Wood River Road 68883 ^ vES ®No
<br />
<br /> 10a. MARITAL STATUS AT TIME OF DEATH ®Marrled ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />!` ^ Married, but aaparated ^ Widowed ^ pivorced ^ unknown Matthew Gideon
<br />d
<br />11. FATHER'S-NAME (First, Middle, Last, Suffix)
<br />12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br /> James Harman Sue Margaret Smith
<br />a
<br />E 18. EVER IN U.S. ARMED FORCES? Give dates of service N Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO PECEpENT
<br /> (Yes, No, or Unk.) NO Matthew Gideon Husband
<br /> 18. ME7HpD OF DISPOSITION 16a. EMBALMER-SIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />r°- ®9urial ^ Donation Derek Apfel 1240
<br />March 3, 2010
<br /> ^ Crematlpn ^ Entombment
<br />
<br />^ Removal ^ Other (Speciry) 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> Wood River Cemetery Wood River Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zlp Goda
<br /> Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 668D1
<br /> ee nstructlona an exam es
<br /> 1s. PART I. Enter thl chain a(avanta••diwaala, Injudet, Ar COmpliCAtlOMdhat AlreCtly uuled the OBath. DO NOT l1lteY terminal evadtt loch At cardiac arrest, APPROXIMATE INTERVAL
<br /> reaplretary arren, or vlnidcular gbrlllatlon without tnowinq ttN nlOlOgy. 00 NOT ABBREVIATE. Enter Only One aura On a Ilse. AAA etltlitlonal Iinei 11 neCSasary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAl15E (Final a) METASTATIC BREAST CANCER 3 YEARS
<br /> dlaaaae or condition reauhlnq
<br /> In dlatnl DUE Tp, OR AS A CONSEQUENCE pF: onset to death
<br /> sequentially nn contllnona, M b)
<br /> any, leading tq the cause Ilatld
<br /> on pnt a. DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE C•)
<br /> (tlIKaW oY Injury that InltiateA
<br /> the Avenel rosuning in aeathl DUE TO, OR AS A CONSEQUENCE OF: ~ onset tq death
<br /> LAST dl
<br /> 18. PART II.OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given in PART I. 18. wAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> ^ YES ®NO
<br />K
<br />W 20. IF FEMALE: 21 a. MANNER OF DEATH R1b. IF TRANSPORTATION INJURY 21 C. WAS AN AUTOPSY PERFORMED?
<br />a ®Not pregnant within pea[ year ®Natural ^ Homicide ^ DdvarlOperetor ^ YES ® NO
<br />~ ^ Pregnant at rims Of death ©AGCldant ~ Pandlnp Invenigation ^ Paawnger
<br /> ^ Not pregnant, Out pregnant within 42 days Af death
<br />^ Sulclda ^ Could not ba determinetl ^ Pedeatrlan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />~
<br />^ NOt pregnant, but propnant 49 days to 1 ysar before death
<br />^ Olher ($psclh!) TO COMPLETE CAUSE OF DEATH?
<br /> [] Unknown N pregnam whnln the pan year ^ YES ^ NO
<br />a
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, arrest, factory, office building, construction seta, etc. (Speclry)
<br />
<br /> 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />O
<br />~
<br />^ YES ^ NO
<br /> 22f. LOCATION pF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP GODS
<br /> 23a. DATE OF DEATH (Mp., pay, Yr.) .
<br />8 g February 27, 2010
<br />~' 24a. DATE SIGNEb (Mo., Pay, Yr.) 24b. TIME OF DEATH
<br /> r 2sb. PATE SIGNED (M11., Day, Yr.) 2SC. TIME pF DEATH ~ ~ ~ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> ~ Z March 2, 2010 07:12 PM 4 ` ~
<br /> ~ 9d. To the bin of my knowlldgl, death vCCUrYetl at the time, date antl place
<br />1S ~ 8 ~ ~
<br />~ ~ p 94e, Dn ttw basis Of examinatitln and/or Invenlgatbn, In my opinion death Occurrod at
<br /> and dos to thl cauw(a) atahd. (Signnuro antl TRN) the rims, dale and place and due t0 the cauw(a) rtated. (Signature and Title)
<br /> ~ Steven Husen, MD ~ a
<br /> 25. DID 7peACGO USE CONTRIBUTE TO THE DEATH? 28a. HAS pRGAN OR TISSUE DONATION BEEN CONSIDERED4 28b. WAS CONSENT GRANTED?
<br /> ^ YES ®NO ^ PROBABLY ^ UNKNOWN ^ YES ®NO Not Applicable If 28a Is NO ^ YE3 ^ NO
<br /> ypa or r tit)
<br /> Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 286. DATE FILED 8Y REGISTRAR (Mo., Day, Yr.)
<br /> March 4, 2D10
<br />
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