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STATE OF NEBRASKA
<br />WMEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT pF HEALTH, 'MJIWN~IN ~SERVlCES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE pRIGINAL RECORD ON FILE WITH THE NEBRA.~„~54 ~Rk~k~fNt~~T C9~ t!-IEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR .1~IT~'{L~k~CO D,~..`' ~`,~. y ,
<br />t~,.
<br />DATE OF ISSUANCE ~~~ ,
<br />s~ 57`A(VL~Y S ~ C~'PE
<br />0$/03/2009 ~r O 1 0 O 3~ O~ l ASSfSTAN~~~E~ISTRAR ~,,
<br />DEP,~~JNE L71~1 AND ".
<br />LINCOLN, NEBRASKA MI,~MAN'St~VICES ' . '
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH ANp HUMAN SERVICES' , ' •.",~~' /'; t .~ •,,!"",'-`. ' .. •r" ' Q9 01636
<br />CERTIFICATE OF DEATH ~ ~ • • .
<br /> 1. DECEDENTS•NAME (First, Middle, Last, Suffix) 2. SEX 3, DATEOF bEATH (Mo., Day, Yr.)
<br /> Robert Samuel Laird Male Jul 24, 2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last BlRhday b. UNDER 1 YEAR 5c. UNDER 7 DAY e. DATE OF BIRTH (Mp., Day, Yr.)
<br /> lyrs.l MOS. DAYS HOURS MINE.
<br /> Cowles, Nebraska 83 August 8, 1925
<br /> 7. SOCIAL SECURITY NUMBER Sa. PLACE OF DEATH
<br /> 507-24-2367 H PI ^ Inpatient OTHER ®Nursing Home/LTC ^ Hosplca Faculty
<br /> 8b. FACILITY-NAME (If not Institution, glue street and number) ©ER/putpatienl ^ Decedent's Home
<br />a
<br /> Grand Inland Veterans Home ^ DoA ~ other (specHy)
<br />~ ec. CITY OR TOWN OF DEATH (Include Xlp Gode) 8d. COUNTY OF DEATH
<br />a Grand Island 68803 Hall
<br /> 9a. RESIpENCE•STATE 9b. COUNTY 9C. CITY OR TOWN
<br />w
<br />z Nebraska Hall Grand Island
<br />~ 9d. STREET AND NUMBER 9e. APT. NO. 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 1704 Idlewood 88803 ®YE$ ^ NO
<br />~
<br />. 10a. MARITAL STATUS AT TIME OF DEATH ®Marrled ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) N wKa, give maiden name
<br />d
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<br />©Marrled, but separated ^ Widowed ^ Divorced ^ Unknown
<br />Marilyn Kathleen Krikac
<br />
<br /> 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br /> Bruce Laird Mable Buzzard
<br />~ 1S. EVER IN U.S. ARMEp FORCES9 Giva dates of service It Yes. 74a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (vas, No, or unk.) Yes 11/15/1943-05/1511946 Maril n Kathleen Laird Spouse
<br /> 15. METHOD OF pISPOSITtON 16a. EMBALMERSIGNATURE 786. LICENSE NO. 15c. DATE (Mo., Day, Yr.)
<br />~
<br />~ ®8urlal ^ Donation Daniel D Naranjo 1071 July 29, 2009
<br /> ^ Cremation ^ Entombment
<br /> 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 TOWN STATE
<br /> ^ Removal ^ Other (Specify)
<br /> Grand Island City Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, State) 17b. Zlp Gode
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Islahd, Nebraska 88801
<br /> AUSE F DRAT ee instructions an exam las
<br /> 18. PART I. Enter the Chain or evente• dieeerea, Injur166, tlr Ctlmplltatitlns-that directly Caused the death. DO NOT enter terminal events each as cardiac arrest, :APPROXIMATE INTERVAL
<br /> respiratory arroet, yr ventricular tlbrillativn withtlul entlwinp the etloltlpy. DO NOT ABBREVIATE. Enter only one Cause on a Ilne. Add addl[Itlnal Ilnea If necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final a) Failure To Thrive 3 Months
<br />- diwaee or wnditlon rosuklnp
<br /> in death) pUE 70, OR AS A CONSEQUENCE OF: : onset to death
<br /> Sequen[Ially flat condltltlne, If b)Chranic Obstructive Pulmonary Disease ~ 1 Year
<br /> any, leading to the cause paled
<br /> on line a.
<br />pUE Tp, OR AS A CONSEQUENCE OF: ~ ., . _. : onset to death
<br /> Enter the UNDERLYING CAUSE C)
<br /> (disease or Injury that Initiated
<br /> the events reaultinp In death( DUE TO, OR A5 A CONSEQUENCE OF; : onset to death
<br /> LAST d)
<br /> 18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death put not resulting In the underlying Cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> Diabetes Mellitus, Coronary ARery Disease OR CORONER CONTACTEp?
<br /> ^ YES ®NO
<br />~
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 214. IF TRANSPORTATION INJURY 21 c. WAS AN AUTOPSY PERFORMED?
<br />~ ^ Not pregnant wlthln past year ®Natural ^ Homicide ^ DrivarlOparotor ^ yE3 ® NO
<br />~ ^ Pregnant At time of death ^ Accident ^ Pentllnp InveMlgati0n ^ Paewnpar
<br /> ^ Not prepnan6 but pregnant wlthln 42 days o1 death Sulclde Could not ba determined
<br />^ ^ ^ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br /> ^ NM pregnant, but pregnant d3 days to 1 year before death ^ Ofher (Spacly) TO COMPLETE CAUSE OF DEATH?
<br /> ^ Unknown ii pregnant wlthln the pdM year ^ YE$ © NO
<br />
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<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, Tarm, street, factory, office building, conatructlon site, etc. (Specify)
<br />
<br />a 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />O
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<br />^ YES ^ NO
<br /> 22f. LOCATION OF INJURY • STREET ~ NUMBER, APT.NO. CI7Y/TOWN STATE ZIP CODE
<br /> " ,~~~ _ _ -. - _. ____ .: _.. .-- -
<br />~ -- -- -- 24a. DA7G$IGNEp (MO., Day, Yr:)- " - 246. TIME aF~AT}r~"_ - __,_
<br /> £ ~
<br />July 24, 2009 ~
<br /> u 23b. DATE SIGNEp (MO., Day, Yr.) 23G. TIME DF DEATH ~' 24c. PRONOUNCED pEAD (MO., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> JUI 28, 2009 06:40 PM H ~
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<br /> O Sd. To the beat of my knvwladge, death ocCUrreA at the time, date and place
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<br />~ x40. On the basis tl1 examinatlon andlvr Inveatlpatlon, In my vpinitln death occurred at
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<br />~ Jennifer King, MD ~ ~
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<br />the time, data and piece and due to t
<br /> 25, pID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br /> ® YES ^ NO ^ PROBABLY ^ UNKNOWN [~ YES ®NO Not Applicable H 25a le NO ^ YES ^ NO
<br /> 2 AM , TI L D A R F ERTIFI yqe or r n
<br /> Jennifer King, MD, 2300 West Capital Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED 8Y REGISTRAR (Mo., Day, Yr.)
<br /> July 29, 2009
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