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STATE OF NEBRASKA
<br />WHEN THl5 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 ORIGINAL ~~~,„WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/S~'Lt I~hi~~yV~^II~IS
<br />,.,.., ~ .
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~ ~•~ ~~ ~ ~ ~ ~~(.~, J
<br />DATE OF ISSUANCE R} a ', . /"',;,,. '• ~ '
<br />ti 010 U~ 5 3 3 a=:~ TANLE'V S c~OPEl9~ ~'
<br />MAY 01 2008 ~~s~~AN T,~E~rE~ISrR~~; W
<br />LINCOLN, NEBRASKA HEA~H AHt~ildl>~N"SLER'f~ICE,~ v''
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND MUMa~1 S~tVi~ .~
<br />1. DECEDENT'S-NAME (Pint, Mlddla, Last Suffix) 2. S ' W y ~ •~ ~ ~ ~.~ T .,DSY,Yr.)
<br />Earl Stanle Irish Male w ` ~ Aqr 241"P~08
<br />a CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 6a. AGE-Cart Birthday 8b. UNDER 1 YEAR 8c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />Brocksburg (Yro.) MOB. DAYS HOURS MIN8.
<br />,Nebraska
<br />7. SOGIAL SECURITY NUMBER
<br />507-28-7797
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<br />ab. FACILITY-NAME (H not Inatltution, giw street and number)
<br />Tiffany Square Care Center
<br />8c. CITY OR TOWN OF DEATH pncluds Zlp Code)
<br />Grand Island 88803
<br />8e. RESIDENCESTATE eb. COUNTY
<br />Nebraska Hall
<br />8d. STREET AND NUMBER
<br />920 N. Oak Street
<br />iea. MARITAL STATUS AT TIME OF DEATW ®Mauled ^ Neva Mart
<br />^ Mauled, but asparoNd ^ Wldowad ^ Diverted ^ UnKnown
<br />78 J L _
<br />8a. PLACE OF DEATH
<br />tJ4~PJTSL: ©Inpatlent
<br />^ ER/0utpatiaM
<br />^ DOA
<br />July 5, 1929
<br />4IHE8: ®Nuning Home/LTC ^ Hospice Faclnty
<br />^ Dscedenri Home
<br />© Other(Sprcify)
<br />ed. couNTY of DEATH
<br />Hall
<br />8c, CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO. H. LP CODE 8g. INSIDE CITY LIMITS
<br />68$01 ®Yas ^ No
<br />18b. NAME OF SPOUSE (First, Middle, Laat, Suffix) H wHa, give maiden name.
<br />Helen Bravek
<br />11. FATHER'S-NAME (Flrot Middle, Lart Sumx) 11. MOTHER'S-NAME (First
<br />Earl Adelbert Irish Zelma
<br />13. EVER IN U.S. ARMED FORCES? Glve datM of service IT Yea. 74a. INFORMANT-NAME
<br />~eSsl'ID, 03/5/48-2/6/53 Helen Irish
<br />18. METHOD OF DISPOSITION 18a. EMBALMER-SIONATURI=
<br />peon"' ^°°"eu°" Not Embalmed
<br />®CrematWn ©EntwnDment
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />^Removel ©otnerySpecily)
<br />Central Nebra$ka Cremation ServiCe$
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />1r. PART I. Enar the rarM.DllIleatl- alweeve, ,ryurwe, °, c°,,,r,,.•,,.,,,•. •••• -•••,
<br />nepirerory emel, er yenWcular DDfI11Hl°n Wlih°ul ehowlna the etl°leyy. DC NOT
<br /> IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />disease or condltlon resulting a)
<br />in death)
<br /> CONSEQUENCE OF:
<br />DUE TO, OR AS A
<br />l;equentially Ilat candltione, I( A
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<br />Any, Iuding to lhs caurr listed (
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<br />on line a. DUE 70, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(dlesaar or InJury that initiated
<br />the events nrulting In death) DUE TO, OR AS A CONSEOUENCE OF:
<br />LAST
<br />eeaeh. DC NOT erMr terml"el evanu such ". eardiec amet
<br />Eller only one cause an a llm. Add rda8lonel Ilne. a neceeellry-
<br />d)
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS-Conditlonr contrlbutiny td the death but not roeultlny In the underlying cause given In PART I.
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<br />20. IF FEMALE:
<br />^ Not pregnant within peat year
<br />^ Pregnant at time of death
<br />^ Not prognaM, but pregnant within 42 dayr of death
<br />^ Nat pregnant, but pregnant 43 days to 1 year before
<br />^Unknown ((pregnant within the past year
<br />Middle, Maiden Surname)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />18b. LICENSE NO. i8c. DATE (Mo., Day, Yr.)
<br />A ril 21, 2008
<br />CITYROWN STATE
<br />Gibbon Nebraska
<br />17b. Zip Ceda
<br />68801
<br />CAUSE OF DEATH (See instructions and
<br />21e. MANNER OF DEATH 21b. IF TRANSPORTATION
<br />Natural ^ Homicide ^ Driver/Operator
<br />^ Accldem ^ PsndinglnvaStipatian ^ Passenger
<br />^ $ulcldr ^ Could not be determinrd ^ Pedratdan
<br />^ Olher (Specify)
<br />J nnee/l to death
<br />I / f•
<br />Dotal to death
<br />I ~ f
<br />onset o~drrth~ yr
<br />1
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<br />onset toi-'- death
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<br />1Y. WAS MEDICAL EXAMINER
<br />qR CORONER CONTACTED?
<br />,YES ^ wo
<br />21c. WAS AN AUTOp~S(y PERFORMED9
<br />^YES /[JNO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />^YES ~O
<br />22e. DATE OF INJURY (Mo., Dry, Yc) 22b. TIME OF INJURY 22c. PLACE OF INJURY~At honor, farm, Stroat, factory, Dino building, tmnetruction alh, sec. (Spaclty)
<br />7.Td:1NJURrATV~ORiCF 2Z8.Ht3NrIN7URY --_.__._. _ _
<br />^ YES ^ NO
<br />2Zf. LOCATN)N OF WJURY -STREET!, NUMBER, APT. N0. CnYlTOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />~~ April 20, 2D08 ~~~
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<br />~ 236. DA ONED ( Da Yr.)
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<br />~~ 23c. TIME OF DEATH ~ ~ k r
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<br />~"~ 1 35D p.m °y~ a
<br />~ y 23d. To the bast y k owledge, death occurred at the Ume, date and place
<br />end duet a s ) t d. ($Igna and Title
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<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yc) ~ 2411. TIME OF DEATH
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<br />24c. PRONDUNGED DEAD (Mo., qey, Yr.) 24d. TIME PRONOUNCED DEAD
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<br />24e. On the basis of axaminatlon endfor invaetigetion, In my opinion death occurred
<br />at the time, date and place and due to the caure(s) Stated. (Slansturo and Title)
<br />26. DID TOBACCO SE CONTRIBUTE TO THE DEATH? tea. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREDT 28b. WAS CON8ENT GRANTED?
<br />.YES ^ NO ^ PROBABLY ^ UNKNpWN ^YES Np Not Applicable N 28a le NO ^ YES ~ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICAN OR COUNTY ATTORNEY) (Type or Pdnt)
<br />Travis Iiageman, M.A.,729 N ,,Custer Av ., Grand Island, Nebraska 68803
<br />28a. REGISTRAR'S SIGNATURE 284. DATE FILED 9Y REGISTRAR (Mo., Day, Yr.)
<br />P ApR S 4 2008
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