|
�- � STATE OF NEBRASKA �
<br />F �; � � ' , , . � • r 2Q1��7835
<br />WM�N THIS GOPY G4RRIE5' THE RqISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL7"H AND HUMAN SERVICES, IT GERTIFIES
<br />THE B�L�W 7'� BF A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH T! NEBRASKA OERAR�M�II(T pF HEALTH AND
<br />� �UMAN S�RVICES, VITAL RECORDS OFFTCE, WHXGH tS THE LEGAC faEPOSIT'ORY FOR VITAL �ORD.9' -��' �.�
<br />DATE OF ISSUANCE ��
<br />STAlVC�1�S. CODPER �,
<br />12/17/20p9 ASSISTANT STATE REGISTRA
<br />DEPARTMENT QF HEALTH ANq
<br />LINCOLN, NEBRASKA HUM ,SERVICES
<br />?�:��. .
<br />STAT� OF NEBRASKA - DEPARTMEN7 O� HEAL7 Fi AND HUMAN SERVI �`� , $ OZ$ �,�
<br />CERTIFICATE OF DEATH �
<br />1. GECEOENTS-NAME (Flnf, MIddN, I.�at 9u1�iz) Y. SEX 3: DA7E OF DEATli (Mq.; O�y, Yr.)
<br />Barbara Louise Caldwell Female December 4, 2009
<br />4. CfTY AND $TA7E OR TERWTDRY, OR FOREIGN COUNTRY OF 61RTW 5a. AG8 • I,.ast Blrlhd�y b. UNOER 7 YEAR Sc. UNpER 1 DAY 6. DAT� OF BIRTN (Mo.. Wy, Yr.)
<br />" Mem his, Nebraska 77 Janua 22, 1932
<br />7. SOCIAL SECURI7Y NUMBER 8f. PLACE OF �EATN
<br />. 505-3&'1594 � � �W� Q� ❑ NvslnY �1LTC � Hdsplp FaCNlly
<br />86: FACR.fTY•MAh1E (1( rlot IrstlqMlOn. 4M drest �nd 1NUrib�1� � ERlOutp�Uant ❑ Wt�d��K'� Horn�
<br />� Saint Francis Medical Center ❑�A ❑� 1sv�iN1
<br />� 8c. CITY OR TOWN OF DEA7H (Includ� 7,Ip Cods) Bd. CpUN'1'Y pf DE�.4TH
<br />Grand Island 68803 Mall
<br />� Aa. RESI�ENCE-STATH 9b. COUNTY 9C. CITY OR TOWN
<br />z NebraSka Hall Grand Island
<br />� 9d. STREET ANP NUMRER . APY'. NO. 9f. LV CbD! 9p. tN81DE CRY LIMfi'e
<br />� 3111 Westside St. 68803 G� v�s ❑ No
<br />� 70a. MARITAL $TATUS AT TIME OF GEATH � Marr4d ❑ Nw�r NYr�i�d 1Qb. NAME OF SPOUSE (F'Ir�R Mlddlp, l.�it, Suf11z) M wif�, plw mtid�n rn�m�
<br />❑ M.rr�.d, nut.oparabd ❑ wwoww p onrorc.a ❑ urrcnown James Caldwell
<br />� 11. FA7HF.1t'S�NAME (FInR MWdh, La�t, SuNbc) 74..MpTNER"8•NAME (Fkrel, YMdN, Mhid�n Sumrmv)
<br />John M Wollen Grace Albers
<br />� 13. EVER IN U.S. ARMED FORCE39 Rlw d�ha of prvin If Ya. 11�. INFORMANT•NAME 14b. qELAT10NSFpp TO DECEp�N T
<br />�ra, No, or uw�.� No James Caidwell Musbend
<br />$ 13. METNOD OF DISPOSfrION 76�. EMBALMER.BKiNATURE 1lb. LIClNBE NO. 76c. L14TE (Mv., �ay, Yr�
<br />� ❑ s�r�ai � oon,don Gerald Quandt 9143 December 4, 2009
<br />� C � ~ �� ��� 16d. CEMETERY, CRBMATQRY pR Q7HER LOC/ATION CfTY / TOWN S'fATE
<br />� R.�o�,� ��•r �sp.�xy� Autumn Hills Cremation Services Qmaha Nebraska
<br />+ra. �unew►� ►�oM� �� nr�o n�w�o �woRess lstr..t, cnr w rown� siaul ��q. z�p cod•
<br />Livinqston-Snndermann Funerai Home, 601 N. Webb Road, Grand Island, Nebraska 68803
<br />li. FART I. Enbr tM duln ot �wnts..dl�r�w. InjuAM, or Co�npllatlonrM�N dlrwMy auMa tM dpth. GO NOT M�W brnMllNl mnn wcn p pMho �nwt.
<br />n�pkatary �m�t. or wMAcWr 116r114qon wMllout �howM�p pM Mlolapy. DO NOT A�YRl1MTl. E�r ony on� wuw on a WM. Add addMbml Nn�r N nwupry.
<br />IMMEqIATE CAUSE:
<br />�M�cure c,w9e �fl� ■) Bradycardia
<br />alt�ap or ea�alqon nrupinn .
<br />�" �� PUE 70, OR AS A CON$lqyEHCE OF:
<br />a.a+.m�.ih i� a�nam�., n b) �all Down Stairs At Fiome Resuldng !n Faclal Trauma
<br />+nY. M�dlnp f0 tM aauN IMpd
<br />on Irr �.
<br />DUE TA, OR AS A C4NSEQUENCL� OF:
<br />em.rm.ur�nrn�mNac�ure clAspiratlOrl Pneumonia
<br />�mw.. or a�uy ma x�u.a
<br />���"�"o �" �' DUE 70, OR AS A CONSEQUENCE OF:
<br />`� dl
<br />aPPROwMnr� iNr�v,n�
<br />on��t to dplh
<br />Less 1'han 1 Hour
<br />wu�t to dwth
<br />3 Weeks
<br />om�t to d�ath
<br />3 Weeks
<br />aM� Eo dMth
<br />te. PAR7 u. PT1iER 81awF1C/WT CpNO1TION8-0andlpon� wnbl6uflrq � tF» d�th but rwt naultlny In th� und�rlylnp csw� phnn In PART I. 1�. WAS MEDICAL ExANMNER
<br />Malign8nt Melanoma With MetasTael6 TO Lunp OR CORONER CDNTACT�G9
<br />p� ❑ YES � No
<br />� • IF K�MALB: �L. MANNER OF DEATW 216. IF TRAN8PORTATION INJU 77c. WAB AN �4UTOp8Y PERFORMEp7
<br />� � Mot pr�0�� wllhln prt YMI � NMunll � Fiomldd� � pl�llOp�Ya�r
<br />� Q WNn��H at NnM of dMlh � AedIMM Q MndMq M�w�GONlen ❑�W� ❑ YE$ � Nd
<br />� L7 � Na prpmm, but pnpn� wpnin u dsn W dx� Q prprnl�n 27d. WERE AWTOPSY FINDIN4$ AVA!{„A
<br />� N� anon.m. bw � a e.ys w � y.0 e.ron eam ❑ iWdd� � eawd noe n. dw�min.d ❑�,�' TO CoMP4ETE CAl16E OF DEATH7
<br />[] ummown x pnynrK wiudn pw pat ywr . Q Y!8 ❑ NO
<br />��2a. DA7H OF INJURY (�, Day� Yr.) ZYb. TIMB OF INJURY 7,4c. PLACE OF INJURY,At horr». hum. �trwy f�c�wY� oRlc� bulWlnp, eorrbuctlan a16�, �. (BP�KY)
<br />November 11, 2009 05:00 PM Home
<br />� 23d. INJIJRY AT WORK7 �. DESCCtIBE HOW INJURY OCCURRED
<br />� fell down stairs
<br />p ves � No
<br />YZL LOCATqN OF INJURY • STREET i NIN�IB@R APT.NO. C17YITDWN ffi7A7E ZIP CpDE
<br />3111 WesTsida Street Grand Island Nebraska 68803
<br />�Sa. �ATE OF DEATN (Mq., pay, Yr.) 24a, pATE $IGNE� (MO., p�y, Yr.) �Ih. Ti1N� OF DEATN
<br />i; December 4, 2009 �
<br />� �} 23b, pAT� SIONLD (Mo„ Dry, Yr.) 2ac. TIME OF GEATH �� Y 24c. PRONOUNCED DEAD (Mo., Day, Yr: ZId. TM�E pRONOUNCED DEAD
<br />-' December 7 2009 12:35 AM ���
<br />� �d. TO tM M�t ef my WqwNpp�. d�Nh 000Yrlyd M IIN IMr. dN� MW PNw � 3M. On th� WMr OTa�aminapon and/or M�wMIp�tlOn. ln �Y OYMbn ArMh ooeumd �t
<br />E� �nd dw to IM uur(r) Whd 1�� � TMM) � � uN qm�, a�a r�e pra �ne ew m m� wu�l rara laqnwun �nd'rvwl
<br />a
<br />~ Jennifer L. Brown, Mp '' �
<br />❑ YE8 � HO Q PRpBABLY ❑ UNKNOYYII YR'8 � Np
<br />L
<br />Jennlfer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebiaska, 68803
<br />;
<br />. REGiSTRAR'8 SN3NATURE .., :: :,:..;:::: , . .: .. . : : : : :: .
<br />No! App11CW1� if 26f i� NO fl YES f'1 NO
<br />2tb. DATE RLED BY Itl418TRAR (Mo., Oay, Yr.)
<br />December 10, 2p09
<br />
|