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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND...HUMAAI SERVICES, IT CERTIFIES
<br />THE BELOW TD BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA,DE'P~Ji~'~MENT70,~ H~,i4LTH AND
<br />MUMAN SERVICES, VITAL RECORDS DFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL REC'4l~DS
<br />DATE OF ISSUANCE ~ I
<br />Q3/05/201 Q 2 O ~ O O ~ ! ~ O ASSISTANT ~T, R~~I~TRAR ':. '
<br />DEPARTM~N7»`I~r~ H~'ALTI-I A"IVD r Y
<br />LINCOLN, NEBRASKA MUMAN ~l7VI,C~S,
<br />STATE QF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES ~ ~~ ~ r
<br />CERTIFICATE OF DEATH _ . , . ~, ~' ..10 00475
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2, SEX 3. DATE OF DEATH ( o.; Day, Yr.)
<br /> Geraldine Erlsne Billin ton Female February 19, 2010
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday h. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yred MOS. PAYS HOURS MINE.
<br /> Grand Island, Nebraska 78 November 30, 1931
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATW
<br /> 507-34-6943 HO$FITAL ^ Inpatient OTHER ^ Nureing HomelLTC ^ Hospice Facility
<br /> Bb. FACILITY-NAME IK not Inetitutlon, give street and number) ^ ER/putpatlent ®Decedent's Home
<br />K
<br />~
<br />V 1210 East 8th Street ^ DDA ^ Other (SpacNy)
<br />w Bc. CITY OR TOWN OF DEATH (Include Zip Code) Bd. COUNTY OF DEATH
<br />© Grand Island 68801 Hali
<br /> 9a. RESIDENCESTATE 96. COUNTY 9c. CITY OR TOWN
<br />w
<br />x Nebraska Hall Grand Island
<br />LL ed. STREET AND NUMBER e. APT. NO. 8f. ZIP CODE 9g. INSIpt: CITY LIMITS
<br />~, 1210 East 8th Street 68801 ®YES ^ No
<br />
<br /> 10a. MARITAL STATUS AT TIME OF DEATH [] Mauled ^ Never Mauled lob. NAME OF SPOUSE (First, Mlddle, Last, Suffix) K wffe, give maiden name
<br /> ^ Marrlad, but separated ®Widowed ^ plvorced ^ Unknown Virgel 81111ngton
<br />
<br /> 77. FATHER'S-NAME (First, Mlddle, Last, Suffix) 12. MOTHER'$•NAMt9 (First Mlddle, Maldon Surname)
<br />~ Frank W Stauss Angela Goodwin
<br />a
<br />E 13. EVER IN U.5. ARMED FORCES? Glve dates of service H Yas. 14a. INFORMANT-NAME 74b. RELATIONSHIP TO DECEDENT
<br /> (Yes, No, or Unk.) NO Bpb 811IIn tpn $On
<br /> 75. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE 78b. LICENSE NO. 78c. DATE (Mo., Day, Yr.)
<br />F ®Burlil ^ Donation Chris McCg 1191 Februa
<br />23
<br />2010
<br /> y ry
<br />,
<br /> [] Cremation ^ Entombment
<br />
<br />^ Rempval ^ Other (Speclry) 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY! TOWN STATE
<br /> Westlawn Memorial Park Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 77b. Zip Coda
<br /> Livingston-Sondermann Funeral Mome, 601 N. Webb Road, Grand Island, Nebraska 68803
<br /> AT ee instructions and exam lee
<br /> 78. PART I. Enter the ~p_djgyy~;-0ISaasas, InJUdes, or compllcatlons-that dlroctly puled the death. p0 NOT enter terminal ewmi tech as cardiac arrest APPROXIMATE INTERVAL
<br /> naplretory arrest, or vanMcular ebdllatlon without shawlnq Tha stl0loey. DO NOT AEBREVIATE. Enter only One cause on a Ilna. Add addkldnal Imes H rreceasary.
<br /> IMMEDIATE CAUSE: Onset t0 death
<br /> IMMEDIATE CAUSE (Final a) Pneumpnia ;Days
<br /> diesels or condition reaukinp
<br /> In daathl DUE TO, OR Aa A CONSEQUENCE OF: pnset to death
<br /> 5equantlally Ilrt condltlona, it b) Severe Oxygen Dependant COPD E Years
<br /> any, laadlne to the puw listed
<br /> on uns a. DUE TO, OR AS A GONSEQUENCE OF: 7 Onset t0 death
<br /> Enter the UNpERLYING CAUSE C)
<br /> (ditsate or Injury that Initlatatl
<br /> the events reaulemp in daathl DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> LAST d)
<br /> 18. PART IL OTHER SIGNIFICANT CONpITIONS-Cpndltlons contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> Diabetes Mellitus, DiBStOIiC CHF, HTN, OR CORONER CONTACTED?
<br /> ^ YES ®NO
<br />W 0. IF FEMALE: 21a. MANNER OF DEATH 27b. IF TRANSPORTATION INJUR 21 c. WAS AN AUTOPSY PERFORMEp?
<br />~ ^ Nat pregnant within past year ®Natural ^ Homicide ^ DAwrlOparetor ^ YES ® NO
<br />~ ^ Pregnant at time oT tlaath ^ Accident ^ Pandlnp Inwatleatlan ^ Paswnpar
<br /> ^ Not prepnaM, but pregnant within 42 days of death
<br />^ sulWde ^ Couid not ba damrmirwd ^ pedastAan 27d. WERE AUTOPSY FINDINGS AVAII-ABLE
<br />
<br />^ Not prednint but propnant 47 days to 7 year beloro death
<br />~ Other (Spaciryl TO COMPLETE CAUSB OF pEATH7
<br /> ©Unlrnown Ir propnant within the part year ^ YE5 ^ NO
<br />~'
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />s
<br />.~ 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />O
<br />t'-
<br />^YES ^ NO
<br /> 22f. LOCATION OF INJURY - STREET S NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.)
<br />-
<br />_ 24a. _D_ATE SIGNED (Ma., Day, Ya) _ .Z4h. II~pE OFDEATH
<br />
<br />_
<br />F$brua 19, 2010 - - -- - -
<br />-
<br />~
<br />ry ~ ~
<br />~
<br /> u.
<br />2Sb. DATE SIGNED Mo., pay, Yr.)
<br />J
<br />( 23c. TIME OF DE
<br />ATH
<br />~ ~ ( 24c. PRQNOUNCED DEAD (Mo., Day, Yc) 24d. 71ME PRONOUNCEp pFAp
<br /> Februa
<br />22
<br />2010 12:55 PM
<br />J
<br />N~
<br />~
<br /> 3d, To the beat of my knowledge, death occurred at tna time, date and place ~ ~
<br />1; 24e. On the basis of examination andlor Invanigation, in my opinion death occurred at
<br /> and due to tM caueatel stated. (Signature and Tidal ~ the time, data and play and due to the gala(s) stated. (Signaturo and Title)
<br /> "' ~ Jay C. Anderson, MD ~
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WA8 CONSENT GRANTED?
<br /> ® YES ^ NO [] PROBABLY ^ UNKNOWN ^YES ®NQ Not Applicable K 28a Is NO ^YE5 ^ NO
<br /> ype or rIM
<br /> Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED 8Y REGISTRAR (Mo., Day, Yr.)
<br /> February 23, 2010
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