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<br />STATE OF NEBRASKA '
<br />` WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH q~l4~k,{4( ,~N SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA~r`17FP,QI2~~ tCZF HEALTH AND
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<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR~,-YfT~l~~~di~C , ~;~ ° " t
<br />DATE OF ISSUANCE
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<br />5T.¢;NL'EY S. CC70PER /.,
<br />Jui s o zoto 201406112 ;ass~~TA~m~-T~RQ~ ~,.
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<br />LINCOLN, NEBRASKA HUPfjA1N 5ERt/ICES ~ r , =
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<br />1 STATE I?F NEBRASKA - DEPARI'MEN7 OF HEALTH AND MUMAN SERVIC~E~ ' • ,~ , ~k• y(~ ~ {7 ~1. •~ [a
<br />R~RTICIRATG t!1C r1CAT41 .L IG,I C ~L ,-!
<br /> 7. DECEDENT'S-NAME (Flret, Mlddle, Last, $umx) 2. sex ,, . 3. q. rH D~,DE~17H (Mo.,Day, c)
<br /> Karen Frances Hunt Female Jul 21, 2010
<br /> 4. CITY AND STATE OR TERRITpRY, DR FOREIGN COUNTRY OF BIRTH Sa. AGE•Last Birthday 56. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTW (Mv., Day, Yr,)
<br /> 1Yra.1 MOB. DAYS HOURS MINS.
<br /> Broken Bow, Nebraska 65 June 12, 1945
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 506-60-5713 HOSPITAL: ©Inpatlsnt OTHER: ~ Nureing Home/LTG ^ Hospice Facility
<br /> Bd. FACILITY-NAME (M not Institutlvn, give street and number) ^ ER/Outpatlsnt ^ Decedent's Home
<br />
<br />Madonna Rehabilitation Hospital LTC ^ DOA ^ Other(Speclty)
<br /> 8c. GITY OR TOWN OF DEATH (Include Zlp Co_ de) -
<br />~ 9d. COUNry OF DEATH " -"~ ~~
<br /> Lincoln 68506 Lancaster
<br />~ ea. RESIDENCE•$TATE 9b. COUNTY 8c. CITY DR TOWN
<br />~, Nebraska Hall Grand Island
<br />.p 9d. STREET AND NUMBER 9a. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY LIMITS
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<br />2403 W, Anna
<br />68803
<br />®Yss ^ Nc
<br /> 70s. MARITAL STATUS AT TIME OF DEATH ®Marr9ad [~ Never Married 106. NAMF~ OF SPOUSE (Firtt, Mlddle, Laat, $umx) N wlTa, give maiden name,
<br />e~ ^ Married,bulasparaeed ^ Widowed ^ Divorced ^ Unknown
<br />Gerald D Hunt
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<br />71. FATMER'S-NAME (Pint, Mlddle, Last, Sumx)
<br />12. MOTHER'S-NAME (First, Middle, Maiden Surname)
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<br />Leo Shultz
<br />0 al Fiske
<br />ry
<br />m 73. EVER IN U.S. ARMED FORCEST Glve dates of asrvlce i}Yes. 14a. INFORMANT-NAME 746, RELATIONSHIP TO DECEDENT
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<br />(Yea, Nn, or Unk.) No
<br />Gerald D Hunt
<br />Husband
<br /> 15. ME7WOD OF DISPOSITION t6a. EMSALME $I ATURE i8b. LICENSE NO. i8c. DATE (Mv., Dey, Yr.)
<br /> ^eadal [fnen.u.n ~, .. ~ Jul 24, 2010
<br /> [~cmmedvn ^6ntombm;ne
<br /> ^R.maval ^Otherlap;city) 18d. CEMETERY, CREMATORY O ?HER LOCATION CIry1TOWN STATE
<br /> Central Nebraska Cremation Services Gibbon Nebraska
<br /> 17e. FUNERAL HOME NAME ANp MAILING ADDRESS (Street, City or Tawn, State) 776. Zlp Code
<br /> Curran Funeral Chapel, 3005 S. LDCUSt St., Grand Island, Nebraska 68801
<br /> CAUSE Op DEATH See Instructions and examples)
<br /> 1e. PANT I. soar the than W ewnb . dlpq;;, In)udu, er compllCetlene-that Oindly ;euNd the dnth. DO NOT;nbr grminel;wnu luC6 u prtllec emet, ;APPROXIMATE INTERVAL
<br /> napintery amst, ar venidcul;r flbdlldlon Wtheut ;hewing the stloloay. DO NOT AaaRlVIATE. Mhr only one eeuu an a line. Add addalonlll Ilnee if neaeesery.
<br /> IMMEDIATE CAUSE: ;onset t0 death
<br />IMMEDIATE CAUSE (Final e F n - y, ,, (''
<br />disetne ar t:ondltlon reauleMg a) _ 7 ~ ~.{ ~ ~ ~~j _ ..., .~ry~i ~ ~~"Q _ . / Y i p Y) a~ l
<br /> In death) r
<br /> pUE TD, OR AS A CON$EOUE.N,CE/~ OF: ;onset tC dsat)1
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<br /> 5aqumtially Ilat candltlona, H ) r ~.[,
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<br />eny, loading to fhe cevxe Ilernd
<br /> on Ilna a. pUE TO, OR AS A CONSEQUENCE OF: ~ onset to death
<br /> Enter the UNDERLYING CAUSE C)
<br /> (disease Or inJury that Initiated
<br /> the events resulting In duth) DUE TO, OR AS A CONSEQUENCE OF: . enact to death
<br /> LAST
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<br /> 18. PART II. OTHER SIGNIFICANT CONDITIONS-0ond{tione contributing to !ha death but not resulting In the undadylnp cause given In PART I. 76. WAS MEDICAL EXAMINER
<br /> ~ OR GORONER CONTACTED?
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<br />S ~ (~ YES NO
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<br />F 2,,,,,0,,,. ~~~IF FEMALE:
<br />~t pnpnant within peel year 21 MANNER OF DEATH
<br />atural ^ Hemlelde 21 d. IF TRANSPORTAT70N INJURY
<br />^ Ddvar/Operator 21 c. WqS AN AUTOPSY PERFORMED?
<br />^ YES ~NO
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<br /> repnene at time oT death Accident ^ Pandlnp Inveetlpetion ^ Passenger
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<br />^ Not prapnent, but pregnant within A2 days of death
<br />^ Suicide ^ Could not ba determined
<br />[~ Pedaatdan 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE AUSE OF DEATH?
<br /> ^ Not pregnant, but pregnant 43 days to 1 year before death ^ Other (Specify) ^ yES ~NO
<br /> ^ Unknown If pregnant within the past year
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<br /> 22a. DATE OF INJURY (Mv., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OFINJURY-At home, farm, alrost, factory, omce building, canatrucpan alto, etc. (Specify)
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<br />O 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />~` ^ YES ^ NO
<br /> 2[f. LOCATiGN O: BJJURY- $TkEEI' 6 NUMBER, APT'. NO. C:krYITOWN STATE JP t:OU6
<br /> 23a. DATE OF pEATH (Mo., Day, Yr.) p~
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<br />~]W ~ ~ 24a. DATE SIGNED (Mo., Dey, Yr.) 24p, TIME OF DEATH
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<br />°~ ~ 236. PATE SIGNED (Mv., Day, Yr,) 23c. TIME OF DEATH
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<br />~ ~ Q 24c. PRONOUNCED pEAp (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
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<br /> y U 23d. To the best of my knowledge, death vccurre at t time, data and place
<br />and due to the causa(ea stela Sl
<br />nal a d Tit µ/ ~ 24a, On the baala oT examination andlor investigation, In my vpinicn death occurred
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<br />o W O 7 at the time, data and place and due to lha cause(s) stated. (Signature and Title)
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<br /> 25, pID 70BACC USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CON$IpERE07 28b. WA$ CONSENT GRANTED?
<br /> ^ YES ~NO ~ PROBABLY ^ UNKNOWN YES ^ NO Nok Applicable N 26a la NO ^ YES ~.NO
<br /> 27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHY ICIAN ASSISTANT, CORD E S PHYSICIAN OR COUNTY ATTORNEY) (Type or riot)
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