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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AIVIa 4dt~ SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASIC~"t7~P,g1~T,~IFNTT`dF• HF,r4GTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VI,~'A~ >f~G'(~RD$ ' ~' ., ~ ~ I ;
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<br />DATE OF ISSUANCE 1 y ~~ ~
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<br />2 o i o o s 4 s~ s~,~nc~t~ s: ~O~P~~
<br />01/19/2010 A.SSISTANTS'T~T~~E~S'7-~tl~ ' ~~
<br />DEPAR7'hIEN~'dF#~.~L ~# AND
<br />LINCOLN, NEBRASKA HUMAN 5E~!VI.CE5
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<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES .~• • ° • ~ r i r ~- ~' , ° O9 Q$'I39
<br />CERTIFICATE OF DEATH .
<br /> L pECEpENT'S-NAME (First, Middle, Last, Suffix) 2.5EX 3: GATE OF pEATf( (Mo., Day, Yr.)
<br /> Jer Ra mond Beck Male December 17, 2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (1'm•) MOS. PAYS HOURS MINE.
<br /> Lexington, Nebraska 70 March 6, 1939
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 506-42-3826 HOSPITAL ^ Inpatient TH R ^ Nursing HomelLTG ~ Hospice Facility
<br /> 86. FACILITY•NAME (If not Institution, glue sVeet and number) ^ ER/Outpatlent ®Decedent's Homa
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<br />U 3508 Graham Ave ^ DOA ^ other (apectfy)
<br /> ~ ec. CITY OR TOWN OF DEATH (Include Zip Code) Sd. COUNTY OF pF.ATH
<br /> `o Grand Island 68803 Hall
<br /> `i 9a. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
<br /> Nebraska Hall Grand Island
<br /> ~ 9d. STREET AND NUMBER e. APT. NO. >ff. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> ~, 3508 Graham Ave 68803 ®YES ^ No
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<br />v 10a. MARITAL STATUS AT TIME OF DEATH ®Married ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) ff wife, glue maiden name
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<br />^ Marrlad, dut separated ^ Wldowad ^ Divorced ^ Unknown
<br />Gaylene Marie Peterson
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<br />11. FATHER'S•NAME (First, Middle, Last, Suffix)
<br />12. MOTHER'S•NAME (First, Middle, Maiden Surname)
<br /> Wilber Beck Esther Eggers
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<br />E 13. EVER IN U.S. ARMED FORCES? Glve dates of service If Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO pECEOENT
<br /> ~ (rea, No, or unk.) Yes 09/02!1958-08130/1962 Gaylene Marie Beck Wife
<br /> °' 15. METHOD OF DISPOSITION i8a. EMBALMERSIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br /> F ®Burlai ^ Donation
<br />Daniel D Naranjo
<br />1071
<br />December 21
<br />2009
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<br /> ^ Gramation ^ Entombment
<br /> 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> ^ Removal ^ Other (Specify)
<br /> Westlawn Memorial Park Cemetery Grand Island Nebraska
<br /> 77a. FUNERAL HOME NAME ANp MAILING ADDRESS (Street, Clty Or TOWn, State) 176. Zlp Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> ee instructions and exam les
<br /> 79. PART I- Enter the chain of avantn •diwesea, Injuries, or complicatlonf•that dirertty uuwd the death. DO NCT ante tennlnal events such as nrdlac arrosl, ( APPROXIMATE INTERVAL
<br /> respiratory errert, or ventYicular flbrillatlon without showing the etiology. DO NOT ABBREVIATE. Enter only ono cause on a Ilna. Add additional Ilnas If nerssaary.
<br /> IMMEDIATE CAUSE: on:et to death
<br /> IMMEDIATE CAUSE (Final a) Gunshot Wound To The Head ;Immediate
<br /> disease or Condition resulting
<br /> in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Svquentialty list Wndkiona, if b)
<br /> any, kadinq to the cause listed
<br /> on line a. DUE TO, OR AS A GONSE011ENGE OF; ; onset to death
<br /> Enter the UNDERLYING CAUSE C)
<br /> (disease or lnJurythat lnklatad
<br /> the events reauking In death) DUE TO, OR A$ A GON$EODENGE pF: onset to death
<br /> LASr d)
<br /> 18. PART II.OTHER SIGNIFICANT CONDITIONS-Condltlons contrlbutlnp to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDIGAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> ®YES ^ NO
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<br /> w 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> ^ Not pregnant within past year ^ Natural ^ Homicide ©DflVerlDperator ^ YES ® NO
<br /> W ^ Prognant al time of death ^ Accident ^ Pending Invertlgatlon ^ Paewnger
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<br />T ^ Not prognant, but pregnant wkhln 42 days of death
<br />®Sulclda ©Could not be tletannined ^ Petlestnan 27d. WERE AUTOPSY FINDINGS AVAILABLE
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<br />^ Not pregnant, but prognant d3 day6 to 1 year beforo death
<br />^ Other (Spacity) TO COMPLETE CAUSE OF pEATH7
<br /> ^ Unknown If pregnant within the part year ^YES ^ NO
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<br />E 22a. DATE OF INJURY (Mo., Day, Yc) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, atreat, Tactory, office building, conatructiOn site, etc. (Specify)
<br /> 3 December 17, 2009 08:00 PM Decedent's Home
<br /> ,~ 22d. INJURY AT WORKS 22e. DESCRIBE NOW INJURY OCCURRED
<br /> F Self-inflicted gunshot wound to the head
<br /> © YES ®NO
<br /> 22f. LOCATION OF INJURY -STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP COPE
<br /> 35D8 Graham Avenue, Grand Island Nebraska 68801
<br /> 23a. DATE OF DEATH_(Mo., Day, Yr. 24a. DATE SIGNED (MO., pa Yr. 24b. TIME OF DEATH
<br /> ~' W ~ January 8, 2010 Approx. 08:00 PM
<br /> g ~ 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ~ ~ ~
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
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<br />~ ~ ~ ~ December 17, 2009 08:50 PM
<br /> p Sd. To the bast of my knowledge, death occurred at the time, date and place $ ~ ~ 24e. On the basis of examination andlor Inwrtigadon, in my vplnlon death occurred at
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<br /> ~ and due to the cau s rta[ad. SI naturo and Thle
<br />~1 1 ( 9 1 the time, date and place and due to lha nuaela) staled. (Slgnrturo and TRIs)
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<br />~ a Martin Klein, Hall Deputy County Attorney
<br /> 25. pip TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREP9 28b. WAS CONSENT GRANTED?
<br /> ^ YES ^ NO ^ PROBABLY ® UNKNOWN ^YES ®NO NotAppllcable H28a Is NO ^YES ^ NO
<br /> L N A RTI I ( Y I N, HY I I N I ype or r nt
<br /> Martin Klein, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br /> 28a. REGISTRAR'S SIGNATURE'' 28b. OATS FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> January 11, 2010
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