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<br />. , - STATE OF NE�RA�KA
<br />� , WHEAI THIS COPY CARRIES THE HAISEl� SE'AL OF TH�' NEBRASKA HEALTH�I1�1D
<br />SYSTEM, IT CERTIFIE'S THE @ELOW TQ BE' A TRUE COPY OF THE pR/C3LN�4 �
<br />THE NEl�RASKA NEALTH AND HUMAN SERVIC�S SYSTEM, V/TAL $�' S_
<br />TH,E LEGAL C1EA�SITpf7Y FOR Vl1"qL RE'CORDS. ;.�
<br />_ _. _ . ._ ..
<br />-, ---.----�---- - ,.
<br />HUMAN SERVIC�'S
<br />C�3l�¢!�N FILE WITH
<br />�F�i/��=Wh!ICM,
<br />�
<br />DATE OF IS3UANCE � '" ��� 1
<br />-..: . s ��AlV�.,�1'` +�
<br />t
<br />.IUL 1 9 Z005 ry ' , a�,�rs��;��,�����������
<br />LINCOLN, NEBRASKA � O�� O l� 4 S �`" �i�;4L'�!"ltl,�(�,G� fi�p�E;��I�YAG�$-
<br />S7ATE qF NEBRASKA- DEPARTMENT OF HEALTH qND MUMAN SERVICES FINAN�E AN(].S�Up_POAT
<br />_ CERTIF'ICAl'� OF DEATM - _� �
<br />1. DECEO�N7'e•NAME (Flrel, Mlddle, Lesl, Sulllx) 2. SEX 3. �A7E DF DEqTH (b1o., Dey, Yr.) �
<br />Bonnie Be11e Trv�.ne Female .7uly 9, 2005
<br />4. CI7Y AN� 9TATE OR T�RRITORY, OR FOREItlN COUNTRY OF 91RTH 5a. AGE-Las1 Blrlhday Bb. UN�ER 1 YFAR Sc, 11NDER 1 bAY 8. DATE OF BIqTH (Mo., Dey, Yr.)
<br />Loup City, Nebrask� Ivre.1 6 � M�3. pAYS HOURS MiNS. May 3, 1939
<br />7, SOCIAL SECUpITY NUM9ER ea. pLACE OF pEATH
<br />5D8--48-2209 Hd PITA � 4 inpaneni �►¢� C] NurslnpHomelLiC ❑HoeplceFad�lly
<br />86, FACILI7Y-NAME �If nat Inslltullon, give elreel and num6er) ❑ EH/outpellant (�1 pecedem'sHome
<br />Home: 81$ N. North itpad
<br />❑ 004 C] Olher(Spec�ly)
<br />8c. CITY OR TOWN OF pEATH (Include Xlp Code) Bd. CpUNTY OF DEATH
<br />Grand Island Ha11
<br />9a. RE3I�ENCE•STA7E eb. GQUMY ec. CITV OH TpWN �
<br />Nebraska Ha].1 Grand Island
<br />9d.5TqE�TAN� NUMt3ER � � 9e. APT. NO 9f, ZIP COqE � 9g. INSIDE CITY LIMIT&
<br />sr8 r�. Npx�r� x o�a 6sso3 �i Y�5 o No
<br />1Da. MARITAL 3TATU9 AT TIME pF DEAiH f��,qarrled � Never Marrled 1nh. NAME pF SPOU&E (Flral, Middla, Lasl, Suflix)11 wlle, give me�den name.
<br />O Marrled, bul aeparaled Q Wldawad ❑ Divorced � Unknown Rab ert Irvine
<br />11. FATNEfi'3•NAM� (Flrsl, Mlddle, Laet, Sufllx) 12. MO7HER'S•NAME (Flrel, Middle, Maiden Burneme)
<br />C1 de Brogden Edith Garrison
<br />13. EVHR IN U.&. ARMEp FORCE59 qlve detas ol eervlce Ilyea. 1qa.INFORMANT•NAME 1�b. WELA7ION8HIP Tq pECEqEN7
<br />�rag,�o, No Ro�ere Ixvine Husband
<br />16. ME7H00 OF oISP031710N iBa. EMBALMER-31GNATlJqB 18G. LICENSE N0. 16c. DATE (Mo.,�oay, Yr. �
<br />❑eudal ODonallon � � -� �� ,T11]_y 12� 2005
<br />�[Cremalion ❑ ENOmbmenl 16d. CEMETERY, CREM ORY Op OTHEH LOCqTION CITY 170WN � 97qTE
<br />❑�Removal � ❑ Olhe� (&pecfly) �
<br />Weatlawn Memorial Crematory Grand Island, Nebraslca
<br />17a. FUNERAL HOME NAME AND MAILIN� AADRE$S (&Ireel. Clty orTown, $lala) 176. Zlp Coda
<br />Apfe7. Funeral Home, 1123 West Second, Grand Island, NE 68801
<br />18. PAHT 1. Enler Ihe Qhal� al evenls--d�seases, InJurlea, or complicallons-•ihal direclly caused Ihe dealh. bp NO7 anler lerminal evenla such as cerdlac erresl, T 'APPROXIMATE INTERYAL
<br />i
<br />resp�rolory arreal, ar vanlrlcular Iibrlllallun wilhaul ahowing Ihe etlology, 90 NOT ABBREVIATE. Enlei only ane ceuae on e Iine. Add addlllonel Ilnes II necessary. �
<br />IMMEDIA7ECAU3E: � onsellodealh
<br />I
<br />IMMEUTATECAUfiE�Finel (� trauma ti0 �tl� t►@A ; immediate
<br />dlaaeeaorcondltlon resulling pUE T0, OR A3 A CONSEDUENCE OF: i onsal lo death �
<br />Indeelh) � �
<br />5equenllellyllatcondlliono,tl (b) � WpllIlC( �
<br />I
<br />any,leadinglotheceuaellaled DUETO,OpASAGONSEql1ENCE0F: I onsellodeelh
<br />vn Ilne a.
<br />Enler the I1NOEpLYING CAUSE . ' . �
<br />(disasaeorin�urylhelin�tlated (°) � �
<br />I
<br />Iha evenh reau111ng In daath) pUE T0, OR AS A CONSEQLIENCE OF: � anaet to dealh
<br />4�
<br />I
<br />(� I
<br />18. PAR711. pTHER sIGNIFICANT CtlN01TItlNS-Condillone conlrl6Winp lo Ihe deelh 6ut not reeulling In iha underlying cause given In PART I. 18. wAS MEDICAL EXAMINEH
<br />Oq CORONEH CON7ACTEtl9
<br />�d YE3 O NO
<br />20.IFFEMALE: 21e.MANNERpFDEATN 21b.IFTpAN&POpTATIONINJURY 21c.WASANAl1TOP3YPERFORMED9
<br />$1 Not pregnanl wllhln pael year � � Nelural ❑ Homlclde ❑ 4dvedOperelor -
<br />� PregneN al Ilme nl dealh [� Accldenla Pending Inveallgallon
<br />❑Pasea�er 0 YES $1 NO
<br />❑ Nol pregnant, but pregnant wllhln 42 deye af dealh C7 pedasldan 21d. WERE AUTOPSY FINDIN6S AVAILABLE 70
<br />� Sulclde ❑ Could not be delerminad
<br />� Olher (qpeclly)
<br />0 Nu� pregnanl, 6ut pragneni q� deya l01 year Uefare deelii COMPLETE CqU3E OF nEATH7
<br />❑ Unknown lf pregnant wllhin ihe pael year G YE5 � NO
<br />22e. �A7E OF INJURY �Mo.. Dsy, Yr.) � 22b- TIME OF INJUflV 2Pc, pLAGF, pK INJI1qY-A1 hvma, �erm, strael, leclnry, olflce 6ulld!ng, cvn.lr�cllon elle, elv. (5padty)
<br />7/9/OS 8:15 a m home
<br />22d.INJURVATWOHK7 22e,pE&CRIBEHOWINJURYOCCURREO �
<br />❑ rES �1NO self i nflicted g w ound �a the head
<br />221. LOCATION OF INJURY � 5TREE7 8 NUMB�R, APL Np. GYY(rpWN . 9TAlF ZIP CO�E
<br />81 8 N. No Road Grand Tsl.and NE 68803
<br />23a.pATEqFPEA7H (Mo.,�ay,Yr.) � 24a.UA7E IGNE� (Mo.,dey,Yr.) 24b.TIM�pFDEA7N
<br />� � �' � � � Z „� . S fll
<br />tT
<br />236. DATE SI�NED �Mo., Dey, Yr.) 23c.71ME OF bEATH �' � 24c. PR NOl1NCED bEqD (Mo., pay,Yr.) 24d. TIME PRpNOUNCED DEA�
<br />� � �'w 7/9/05 �.�:QQ a I7�
<br />��� 23d.Ta Ihe 6ea10l my knowledge, dealh occurred at Ihe Ilme, dale and place $�� 0 2qa. On Ihe basls of examinallon endlor Invesligallon, In my opinlon death occurred al
<br />F � end due lo Iha causa(s) alaled. (Signalure end Tltla ) r ��� „ l�ie tlma, dale and pl@ce end due Io the cauee(s) slslgd. (Slgnalure and Tille ) r
<br />o � I
<br />C o Q
<br />U � �..
<br />25.�IbT06AGG0USECONTHIBl1TETOTHEDEATH9 28a.HA80RGANORTI55UEDONATIONBEENCON5IDEREp7 � 286.WASCON NT I7ANTEbT �
<br />!/
<br />C] YE& NO ❑ PRPBA9LY ❑ UNKN�WN O YES � NO Nol Appllcable 1128a le NO ❑ YES � NO
<br />27.NAME,TI7I.EANbADDRES30FCEpTIFIER (PHYSICIAN,CDRONEp'SPHYSICIANORCOl1NTYAT70RNEY) (TypeorPrinq
<br />Sarah Carstensen De ut Ha11 Count Attorne : 231 S. I,ocust, Grand Island NE
<br />28e. pEGISTflAR'S91pNATUpE � • 286. dATE FILEp BY REpISTRAR (Mo., l7ay, Yr.)
<br />����� � �,r� . �u� � 5 zoo�
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