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STATE OF NEBRASKA
<br />�� WHEN THI5' CDPY CARRIFS TME RAISED $EAL pF THE NEBRA$KA DEPARTMENT OF HEALTH,�AlL9�F $ERVIG'ES, �`T CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF TWE ORIGINAL`R�CORD �N FILE WITH TME NEBRASICA" p.� /� F1(�"q� M�ALTH AN�
<br />HUMAN S�RVICES, V11"AL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR. �TA�'� �ORD�,` :;� 3�
<br />� � � r
<br />DATE OF ISSUANCE � � �'� � ?
<br />AU G 2 � 2Q 10 � ��a�i��Y . eoo'PE� � ' . � , �,
<br />2oioosoo� As��� �_ ���� � .
<br />v��aarM�r� ��f►�;�NC> ; '
<br />LINCOLN, N�BRASKA H,hJN�YN.SERVIC�S , , ,.�
<br />STA7E OF NE�RASKA - D�PARTM�NT OF HEALTii AND HUMAN &ERViG�S l� .; �•��' ' ��� J � ' �' µ J�! . ' ° �� - •�!, �
<br />ERTIFICATE O TH � �� r .'�.' • '�• °`� �
<br />1. DECEtlE'Nl"8-NAME �FIrBt, Mitldle, Lase, $ufflx) 2. SEX M1 '8• [1q & pIF •[�EI�TM (0.1o:,Aay�;�'r.�
<br />Charles Robert Frith Male Au ust•9, 2010'
<br />4. CITY pN� STATE OR TERRITORY, pR FOREIGN COUHTRY OF BIRtH 5a- AGE-Last Blrthday Sd. UNdER 7 YEAR 6c. UNDER 1 OAY 6. pqTE �F 81RTH (Mo., D9y, Yr.)
<br />(Vrs.) MOS. DAYS HDURS MINS.
<br />Rogers, Arkansas 77 June 30, 1933
<br />7. $tlC1AL 3ECURITY NUM6ER Ba. PLACE OF DE4TH
<br />443-30-4963 H, OSpITAL. � Inpatlent OTHER: [] NursinA HomelLTC � Hosplce Facility
<br />84. FAGILITY-NqME (If 11tlt 1115t1t�tl011, glv0 gtfe¢t 811C 1111111b¢I'� � ER(011tpBttetlt n OecedenYs H01114
<br />BryanLGH Medical Center East � DOA pou,ahspac�ry�
<br />Bt. CITY 6R 70WN OF �EATH (Inclutla Ylp Code) 8C. CtlUNTY OF �EATH
<br />� Lincoln 68506 Lancaster
<br />ea. ftE51DENCESTATE 9b. CDUNTY 9c. GITY oR ToWN
<br />�
<br />� Nebraska Hall • Grand Island
<br />�� 9d. STREET AN4 NUMBER 9v. APT. NO. 9f. ZIp COOE 9g. INSIDE CITV LIMITS
<br />� 46D3 Deva Qrive 68801 � re5 � No
<br />� 14a. MARITAL 8TATU5 AT TIM� OF DFJITH � MaRled ❑ Never Marriad tOb. NAM� OF SpOUSE (FIrBt, Mlddla, Last, SufflX� HwifO, glve maldep name.
<br />�y ❑ Married, nut9eperated ❑ WidoWetl ❑ DlvafFed [� UnknoWn BeSSIe E Baker
<br />� 11. FATMER'SNAME (FIfSt, Mlddle, Last, Su(flx) 12 MOTHER'S-NAM� (FJrst, � Mlcitlle, Maldan 3urnama)
<br />�+ Jose h Lewis Frith LaVawn S. Ste henson
<br />� 13. EVER IN IJ.S. ARMED FORCEST �IV¢ tlffieS Of 6BrvICe IT Y98- 14a. INFORMANT-NAME ��� � W 1A6. RELA710NSHIP TO DECEDENT
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<br />F' (Yes,No,arUnk.) ygg 2/1954 2/1958 Bessie E Frith Wife
<br />95, ME7HOO oF oISPO517loN 16a. EMOALMEFj${�3NATUR � 16b. L�CENSE No. tsc. DATE (Mo., Day, Yr.)
<br />�e�,;Ai poo�up� �ODA r f 8/12/201p
<br />�cr.mauvn ��nnmhma�x
<br />Q rtemovei �tltheqepscifyl �Bd• r''��ETERV, CREMATORY DR OTMER LOCA710N CITVROWN 5TATE
<br />Grand Islend City Cemetery Grand Island Nebraska
<br />17a. FIINERAL HOM� NAME AND MAILING ADORE5.�i (511plt, Clty 4� Tawn, state) , � �n. zip cnde
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 688q1
<br />Butherus-Maser & Love Mortuary, 4040 A Street, l�incoln, Nebraska �Q� 68510
<br />CAUSE OF DEATH See instructions and exam les)
<br />18. PAR71. �rnu eha oRaln alevems- dleeaaes, Inµidee, or campNcwiona-that dinaiy aauaad 1M death. Po NoT srper �emJnd ereMe wch ae cardiac arr�s4 ; APPRDXIMATE INTERVAL
<br />faapifmtlry pRap, a� VOnMCUIer 116r111etlon wllhoue eha�Hnp tM e[idapy. GO NOT ASBR@VIRTE. ENSr aMy ona eeu�e en e q�x, Add eddillanel Nnee H mceaeery.
<br />IMMEDIATE CAUSE: ; pngetta death
<br />IMMEDIATE CqUBE (Flnal �
<br />dlsaase ar conditian resulting a) A I .Q �
<br />In death) � "' ( �
<br />DuE To, oR AS A CONSEpIJENCE OF: ; onset to deatll
<br />SequOntlslly Iist conditions, If d) ��� ��� -. 1' 1 _
<br />/JA V J
<br />any, I�ading to the causa Ifated \ vV �,��+
<br />an IInB a. pIJE TO, OR AS A CONSE ENCE OF: � on et to death
<br />Enter Me UNpERLYINO CAU3E �) { �IY 1 � S�� � � I
<br />(dlsease or Injury that Initlated �''� �
<br />the eventa resulting in death) DUE TO, OR AS A CONS CIUENCE OF: set ro death
<br />LA9T
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<br />19. PART 11. OtHER SIONIFICAN7 CONOITIONS-Condftlens ConVlbuting to the dealh but nat resultlng In the undarlying causa giVen in PART 1. 18. WAS ME�ICAL EXAMINER
<br />OR CORQNER GQNTAGTEp9
<br />❑ YES �O
<br />y�,� 20. IF FEMAL�: 21 a. MANNER OF DEATH 216. IF TRANSPORTATION INJURY 2/c, WAS AN AUTpPSY PERFQRMED7
<br />� ❑Not pregnant wlthln paRtyear . ,�Natural ❑ Hemlelde � pllverlop0ldttlr ❑ YEs
<br />� �Pregnant at time af deatt� � ACCldaqt [� Pending inwstiganon [] Passenger
<br />W 21d. WERE AUTQPSV pIN�INGB AVAII„ABLE
<br />�1 []Nat prognant, 6ut pragnantwithin 42 daye af daath ❑ 3WCIde Q CoWtl OOt 6Y dititri110od Q PGtlr8tl'iea TO COMPLETE CAl13E OF L7EJ1TH7
<br />� ❑ Not preqnant, aut pregnant 43 daye to 1 year before death ❑ Othar (Speciry) ,
<br />❑ YES ❑ Nd
<br />�� [] llnknown If pregnant wlthln thg past year
<br />3 ��
<br />F 22a. DA7E OF INJURY �Mn., Day, Yr.) 22b. TIME OP INJURY 22c. PLACE OF INJURY-At home, farm, streM, hctory, nfflce bullding, construcdon slte, etc. (5peclTy)
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<br />m 22d. INJURV AT WORK? 22e. �E3CRIBE HOW INJURV OCCURREO
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<br />�' ❑ YES ❑ Ntl
<br />22(. LOCATIqN qF INJIIRY -STREE7 8 NUM�ER, APT. NO. CITYITOWN STpTE ZIP CODE
<br />28a- DATE pF OEATH (Mo., Oay, Yr.) � 24a. pATE SI6NED (Mo., Oay, Yr.) 246. 71ME OF DEATH
<br />�� - q- I �
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<br />°� r 23h. DATE SIGNE (Ma., �ay, Yr.) 23c. TIME OF �EATH � y� 24c. PRONOUNCE� DEA� (Ma., Day, Vr.� 2dd. TIME PRONOUNCEO OEAA
<br />C�2�}
<br />�40 !f :`� O.m o m
<br />�J 23d. To the dest of my ktlowledg¢, death OCCUIT2d 9t thB Ht11B, ddt0 811d pIBCe �� g 24E. tltl th4 bd515 Of eXd011113t1011 aPdla� InVlStlgation, in my opinian deaM accurred
<br />� p and due to tha cause(s ta .(Signatuce sntl Tnia} �' 0 O at tne dme, dste entl place and due ro the cause(s) stated. (Slqnature and Tltle)
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<br />25. DID TOBACCO USE CtlNTRIBUT� 70 �EATH7 76a. A ORGAN OR TISSUE �ONATItlN BEEN CONSIDEREA7 266. WqS GONSENT GRANTED?
<br />. � VES � NO [� PROBABLY NOWN YES ❑ NO Not Applicable If 268 Ia NO ❑ YE5 p
<br />C 27. NAME, 71TLE AND AD�RESS OF CERTIFIER �PHY5ICIAN, pHVSICIAN ASSI57A 7, CORONER'S PHY81tlIAN Oa COUN7Y ATTORNEY) (Type or Pdnt)
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<br />c. � . � (.QD 1.,i1n n r
<br />28d. REGISTRAR'S SIQNATURE 28b. DATE FILED BY REGISTRAR (Ma.,,Day, Yr.)
<br />� ,�• AUG Y 8 2010
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