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STATE OF NEBRASKA
<br />* WH(~N THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND, H(,//4}.4~V SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA_L3EPARTMEIVT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE WHICH IS THE LEGAL DEPOSITORY FORlVITAL„ Fj~'CORDS:
<br />DATE OF ISSUANCE ~~/~I~~ ~L1 ~ ~'~•
<br />STANLEY S. COOPER"
<br />02/24/2010 ,~~ ~ 1 O 0 5 9 6 ~ ASSI5~,4NT sT~TE f~FG~s'~!l~AR .
<br />DEPAft:TMENFT-Uf..d1EA1C . .;~Nd -
<br />LINCOLN, NEBRASKA HUMAN, SERVICES ,
<br />STATE dF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES. "•, ~ d dQ468
<br />CERTIFICATE OF DEATH ~~''' ~" •- ±' ~ -°• ~ .
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX 81 pATE,OF pEATH (Mo., Pay, Yr.)
<br /> Levern Edward O'Brien Male ~ebrua 18, 2010
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY e. DATE OF BIRTH (Mq., Day, Yr.)
<br /> (Yn.) Mpg, PAYS HOURS MINE.
<br /> Grand Island, Nebraska 66 January 15, 1944
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 507-62-2363 HOSPITAL ^ Inpatient OTHER ®Nursing Noma/LTC ^ Hoaplce Facility
<br /> 8b. FACILITY•NAME (K not Instltutlon, glue street and number) ^ ER/Outpatlent ^ Decedam's Home
<br />
<br /> Western Hall County Good Samaritan Center ^ DpA ^ pther(specly)
<br /> 8c. CITY OR TOWN DF DEATH (Include Zlp Coda) ed. COUNTY pF DEATH
<br />o Wood River 68883 Hall
<br /> 9a. RESIpENCESTATE 8b. COUNTY 8c. CITY OR TOWN
<br />w
<br />z Nebraska Buffalo Shelton
<br /> 9d. STREET ANp NUMBER 8e. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY LIMITS
<br /> 8781 5. Bluff Center Road 6$$76 ^ YES ® ND
<br />
<br /> 1Aa. MARITAL STATUS AT TIME OF DEATH ®Married ^ Never Married 1A6. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br /> ^ Marrlad, but separated ©Widowad ^ Divorced ©Unknown Connie Powers
<br />d
<br />11. FATHER'S•NAME (First, Middle, Last, Suffix)
<br />12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br /> William Roswell O'Brien Doris Grace Lange
<br />a
<br />E 13. EVER IN U.S. ARMED FORCES? Glve dates of service if Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yea, No, or Unk.) NO Connie O'Brien Wife
<br />~ 15. METHOD OF DISPpSITIDN 18a. EMBALMER•SIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Pay, Yr.)
<br />H ®Burlal ©Donatlon
<br />Tracey Dietz
<br />1328
<br />February 23
<br />2010
<br /> ,
<br /> ^ Cremation ^ Entombment
<br /> 16d. CEMETERY, CREMATORY pR OTHER LOCATION CITY /TOWN STATE
<br /> ^ Removal ^ Other (Specify)
<br /> 5t. Mary's Cemetery Wood River Nebraska
<br /> 17a. FUNERAL NOME NAME ANp MAILING ADDRESS (Street, City or Town, State) 17b. ZIp Code
<br /> Apfel Funeral Nome, 1123 W. 2nd, Grand Island, Nebraska 68801
<br /> AU E F EATW ee ns roc ions an exam es
<br /> 78. PART I. Enler the chain ehwnts--0leaaias, InJurles, or compllcatlone-that dlreclly cau9ed the death. p0 NOT Bmer terminal events eUCh as CArdlaC arrest, APPROXIMATE INTERVAL
<br /> nsplrattrry amat, or ventricular Bbrlllatlrln without algwlna the etbloey. Dp NM AeBREVUITE. Enter only one taus on a Ilne. Add addidonal lino if necessary.
<br /> IMMEDURTE CAUSE: gnsgt to death
<br /> IMM~DUTracAUSEiFriir '~1fulETASTATIC HEPATOCELLULAR CANCER 4 YEARS
<br /> disease or condltlan reauhlna
<br /> In death) pUE TO, OR AS A CONSEQUENCE OF: ; Onset to death
<br /> Sequentially Ile conaltlona, if b)
<br /> any, hadins to the uuw Ilnad
<br /> on sins a. DUE TO, OR AS A CONSEQUENCE OF: I gnset tq death
<br /> Enter the UNDERLYING CAUSE ~)
<br /> (dlwaw or InJury that Initiated
<br /> the events resualnp In death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br /> I~sT d1
<br /> 18. PART II.OTHER SIGNIFICANT CONDITIONS•Conditlons contributing to the death but not resulting In the underlying cause given In PART 1. 18. WAS MEDICAL EXAMINER
<br /> pR CORpNER CONTACTEp7
<br /> ^ YES ®Np
<br />~
<br />W 26. IF FEMALE: 27a. MANNER pF DEATH 27 b. IF TRANSPORTATION INJURY 21 c. WAS AN AUTOPSY PERFORMED?
<br />~ ^ Not pregnant withid peat year ®Naturel ^ Homicide ^ DriverlOperelor ^ YES ®NO
<br />~ ^ Pre9nam at time q( death ©AcCident ~ PenAine Inveetipation ^ Paaeenee!
<br /> ^ Nat pregnant, but pregnant whhln 4Z days of death
<br />^ 8u1Gde ^ Could not be determined ^ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />
<br />^ Not pregnant, but pregnant 4] days to 7 year 6efaro death
<br />^ Other (Specify) TO COMPLETE CAUSE OF DEATH?
<br /> ^Unknown I(proenant whhln the past year ^ YES © NO
<br />a
<br />E 22a. DATE OF INJURY (Mq., Day, Yr.) 22b. TIME pF INJURY 22c. PLACE pF INJURY•At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />
<br /> 22d. INJURY AT WORK? 22a. DESCRIBE NOW INJURY OCCURRED
<br />0
<br />~
<br />^ YES ^ NO
<br /> 22f. LOCATION OF INJURY • STREET 8 NUMBER, APT,NO. CITYITOWN STATE ZIP CODE
<br /> 23a. DATE OF pEATH (Mo., Day, Yr.) g4a, PATE SIGNED, (Nb., Day, Yr.) ~ P4b.'T18ME'OF18~tf1'°^'"" ' - ' ' ~ "
<br /> S W February 18, 2010 ~
<br /> ~ 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ~ ~ > 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> Februa 23 2010 11:59 PM ~ ~
<br /> To the best of my knowlsdea
<br />death occurrrod at the time
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<br />+~+ and due to the aueele) stated
<br />181gnature and Title)
<br />+~ £ ~ yqe. On the basis of examination anNor investlyatlon, In my opiNon death occurred at
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<br /> ~ Steven Husen, MD ~ ~
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CpNSIDERED7 26b. WAS CpNSENT GRANTEb7
<br /> ^ YES ®NO ^ PR08ABLY ^ UNKNOWN ^ YES ®NO Not Applicable If 28a Is NO ^ YES ^ NO
<br /> I 1 1 N I A ype or r nt)
<br /> Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 286. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> February 23, 2010
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