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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF MEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA. DEPARTMENT OF MEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL'kECQRD.S'.q
<br />DATE OF ISSUANCE ~~•~) ~ ~ ~
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<br />~a~ ~ 2 2a~a A~~~~ ~~r~~`~ ~~~~~y~
<br />O ~ O O ~] ~ 3 ~ DE~+,AR'7`h4ENT ORLTN AND _~^'•~
<br />LINCOLN, NEBRASKA a7 HU~'IA,~I S~R~~C~a ,, ;
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<br />STATE OF NE9RA51(A- pEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND S1JPRb ' ' •
<br />CERTIFICATE OF pEATH ~•~~;-;~ ~~~. ~'~
<br /> L DECEDENT'S•NAME (First, Middle, Lest, ~f ~ Suffix) 2. SEX " ; 3.19ATE"OF tEr~rA (MO.,Oay,Yr.) ~°' '
<br /> Craig Lee
<br />Gibson Male are'4i,' "1`3 '' 20I0 '
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<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5e~. AGE•Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE DF 81flTH tMd:, Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINE.
<br /> Grand Island, Nebraska 60 Aecember 13, 1949
<br /> 7. SOCIAL SECURITY NUMBER 89. PLACE OF DEATHT
<br /> _~ SQ$-6Q-0.254
<br />~, HOSPITAL: O Inpatient 4Il~S ^ Nur6ingHomehTC ^HdapiceFacility
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<br />86. FACILITY-NAME (If not institution, glue street and number) _
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<br />^ ER/putpalient .~"Oebedent'a Home
<br /> 1609 North Kruse ^ Dav ^ Other(speciry) ---
<br /> Bc.CITYORTOWNOFDEATH (IncludeZlpCode) Sd.000NTYOFDEATH
<br /> Grand Island, Nebraska
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<br /> Sa.RESIDENCE-STATE _
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<br />86.000r41'Y ~~ 9c. CITY OR TOWN
<br /> Nebraska Hall Grand Island
<br /> 9d. STREET AND NUMBER ~~ 9e. APT. Nq 8t. ZIP CODE gg. INSIDE CITY LIMITS
<br /> 1609 North Kruse 68803 OYES ^ NO
<br /> 10a. MARITAL STATUS AT TIME OF DEATH Merrlad ^ Never Merrlad tOb. NAME OF &POUSE (FIr66 Middle, Last, Sunlx) If wits, give maiden name.
<br /> ^Merrlad, but separated ^ Widowed ^ Divorced ^ Unknown
<br /> Kim Kroeger
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<br />11. FATHER'5•NAME (First, Middle, Lae6 Suiflz) _ _
<br />12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br /> Theodox'e Gibson Pearl Na for
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<br />146. RELATIONSHIP TD DECEDENT
<br />13. EVER IN U.S. ARMED FORCE59 Glve dates of eervlca If yes. t4a.INFpRMANT•NAME
<br /> (Yee. no. or unk) Np Kim Gibson Wife
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<br /> 186. LICENSE Np. 16c. DATE (Mo., Dey, Yr. )
<br />75. METHOD OF DISPOSITION 18a.EMSALMER-SIGNATURE
<br /> ^Bural ^Donation Not Embalmed ___ March 1S, 2010
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<br /> STATE
<br />'Cremation ^Entambment 1Bd.CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN
<br /> ^ Removal ^ Other (Speclly)
<br /> Westlawn Memorial Park Crematory Grand Island, Nebraska
<br /> 77a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty orTOwn, State) 17b. Zlp Code
<br /> Livingston-5ondermann F.H. 601 N. Webb ltd. Grand Island, Nebraska 68803
<br /> 18. PART I. Enter the c11ei"R-ssente••tliseasea, In)ur!es, or compllcetion6--that dlreatly nau6ed the deem. DO NpT enter terminal events such as cardiac arrest, I APPROXIMATE INTERVAL
<br />- ~'~ reeplratory arrest, or ventricular ri6rillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilse. Add addlllanal lines 8 necessary, i
<br /> IMMEDIATE CAUSE: I onset to death
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<br />IMMEDIATE CAUSE (Final
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<br /> dlaaaee pr oondltlon nauhing pUE TO,OR ASACONSEOUENCE OF: i ~gnset tO death
<br /> in death) .X I J'~
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<br />Sequentially list canditlone, It (b) 1 V 1~tCn. , '~~ ~]'(,~ ('~, I
<br /> any, leading tothacauaallated DUE70,ORASACONSEOUENCEDF: I oneettodeath
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<br /> Errter tlw U NDERLYINO CAUSE
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<br /> theeverderesuhinglndeelh) pUETD,ORASACONSEQUENCEOF: .~.._...-._..~-.__.~., i onset to death
<br /> EASE i
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<br /> 18. PART IL OTHER SIGNIFICANT CONDITIgNS•Condltlons canhlbuting to the death but not resulting in the underlying cause given in PART I. x~~g WAS MEDICAL EXAMINER
<br /> `OR CORONER CONTACTED?
<br /> ^ YES ~l NO
<br /> 20. IF FEMALE: __ 21a.MANNEROFpEATH 21b.IFTRANSPORTAT10NINJURY 21c.WASANAUTOPSYPERFORMED7
<br />n ^ Nat pregnant within past year X Natural ^ Homicide ^ Driver/Operator }(
<br />^VES ~+NO
<br />- ^Pessenger
<br />^ Pregnant at time of death ^ Accltlent^ Pentling Investigation
<br /> ^ Peda6trlan
<br /><J Nvt pregnant, but pregnant within 42 days of death ^ Suicide ^ COUId not be determined 21 d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br /> ^ Not pregnen6 but pregnant 43 days to 1 year betas deem ^ Other (Speclly) X COMPLETE CAUSE OF DEATH7
<br /> (J Unknown if pregnant within the peal year ^ YES ^ NO
<br /> 22a. PATE DF INJURY (MO., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, term, street, lactory, office building, construction site, etc. (Speclly)
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<br />22d.INJURYAT WORK7 22e. DESCRIBE HOW INJURY OCCURRED ~`
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<br /> 22f.LOCATIONOFINJURY•STREETBNUMBER,APTNO. CITYROWN SINE ZIP CODE
<br /> 3a. DATE OF DEATH (Mo., pay,Vr.) z } 249. DATE 51GNE0 (Mo., Day, Yr.) 246.TIME OF DEATH
<br /> 2010 ~'~~ m
<br />~'~ March 13
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<br />- H 23b.DATESIGNEp(MO..Day,Yr.) a3c.TIMEOFDEATH ~_~ 24c.PRONOUNCEDDEAp(MO..Dey.Yc) 24d.TIMEPRONOUNCEDDEAD
<br /> ~~ z 2:15 .m. m "a€ m
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<br />w ~ 24e, On the basis o1 examination andlOr InVeetlgatlon, In my opinion death occurred at
<br />x~,,," 23d. To the best of my knowledge, death oCOUrrod at the time, date end place
<br />the time, data end place and due to the cause(s) stated. (signature and Title)
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<br />~r o end due to the cause s) slated. (Signature and Tlne) • ~ ~
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<br />25.DIOT08A000U5ECONTRISUTETOTHEDEATH7 28a.HA50RGANORTISSUEpONATIDNBEENCONSIDERED?
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<br />, • J YES ^ NO
<br />^ VES ~,ND Not Applicable i128a is NO C
<br />^ YES ~ NO ^ PROB
<br />ABLY ^ UNKNOWN
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<br />27.NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN,CORONER'B PHYSICIAN DR CDUNTY ATTORNEY) (Type or Print) I
<br /> ~ ~zq W Cl~~'~~ C~-`ld l C~ F' 1J~, LG ~'[~3 Jennifer Broran M.D.
<br /> 28a. REOISTRAR'SSIGNATURE 286. DATE FILED 8Y REGISTRAR (Mo., Day, Yc)
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<br />HHS-81 11103 (55067 )
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