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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED $EAL OF THE NEBRASKA HEALTH ANU HUMAN S�h7VlCES
<br />SVS�'�M, lT CERTIF/ES THE BELOW TO BEA TRUE COPY OF THE pRlGll�lA��fC�FhR�N FILE Wl7'N
<br />TWE NEBRASKA HEAL7'H AND HUMAN SERVICES SYSTEM, VITAL ST��ISTlE�=S�T�(C�_WNICH 1S
<br />THE LEGAL DEPOSITOFtY FOR VITAI RECORD3. , __ ;� �
<br />DATE OF ISSUANC� -
<br />APR 14 200�3' (� Q ry - _,�vc�vs:�vt�P�r�
<br />2 V� Q Q O/� O � ASSISTAN� ST,4,T� F1E_Gl�l'"ftAR
<br />LINCOLN, NEBRASKA �•HEAL'TH�4ND HUMAN SL�#i//EES
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<br />STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SE:iVIC�S FINANCE ANI7�UPRORT '
<br />cE��ri�icAT� o� u�a�r � Q 5 � 0 8 5
<br />1. DECEbENT'5•NAME (First, Middle, Lest, Suflix) 2. 3EX 3. DATE OF �EATH (Mo., Pay, Yr.)
<br />Barbara Mae Tams k'emale April 6, 2005 _
<br />4. CITV AND STATE OR TERRITpRV, OR FOREIGN COUNTRY OF 81RTH 5a. AGELast Blrihday 56. UN�ER 1 YEAR 5c. UNbER 7 OAY 6. DA7E OF B1RTH (MO�, Oay, YI.)
<br />(Yrs.) MDS. DAY5 HOl1R5 MINS. �
<br />.Grand Island, Neb�aska 71 _�_ Novemb�r 25, 1933
<br />7. SOCIAL 5ECURITY NUMBER Be. PLACE OF DEATH
<br />505-36-7796 WOSPITAL: CV 'npatienl Ol}i�p ❑ NursingHvme/LTC UHoeplceFaclllly
<br />_..._. ..._....�_..___ ...,(_.... _ . _,._...._ ... ....��� _.;,..�....
<br />8u. °ACI�,.JTY-PFAFlE - li nui �nsti(uiiun. 9iva st - . .- . _ . � . ..- . ._..- .. .,.�.,� ; •-�» r. .-m.,�. . .. . _
<br />��ER10utpaflent DecedenYeHome
<br />215 E. Church Street ❑�,, ❑ Olher(Specify)
<br />Bc. CI7Y OR TOWN OF bEATH (Includa Zip Code) ed. COl1NTY OF DEATH
<br />Cook ,lohnson
<br />... . . _ .. � ..._.- - --...._._
<br />9a. RESI�ENCE•STATE 96. Cql1MY 9c. CIN OR TOWM1
<br />Nebaraska John Cook
<br />9d.5TREETANDNUMBER T T . J+e.APT.NO 9f.ZIPCODE
<br />2�.5 E. Chu�ch Street 68329
<br />10e. MARITAL 5TAT115 ATTIME OF DEATH �] Marrled ❑ Never Marrled 106. NAME OF SPOUSE (Flrel, Mlddle, �_ae6 Sulflx) It wl�e, glve malden name.
<br />❑�Merrled, hul sepereted ❑ Widawed �❑ Dlvorced ❑ Unknawn RQ�gZ ' T�IIIS
<br />9g. INSIDE CITY LIMIT5
<br />�] ves ❑ No
<br />11. FATHER'S-NAME (First, Middle, Lesl, � SuNlx) 12. MDTHER'S-NAME (Flrat, Mlddle, Maiden Sumame)
<br />Louis Sander Lenore Ha�pold
<br />13. EVEF IN U.3. ARMEP FORCE57 O�ve dates of service If yes. 14a.INFpFMANT•NAME 14p. RElATI0N5HIP 70 �ECE�ENT
<br />(Yas, no, or unk.) NO Robext Tams Husband
<br />15. ME7HOb tlF nISPtl5�TI0N 16a. EMBALM -510NA i6is: LICEN5E N y i6c. �ATE (Mo., �ay, Yr. )
<br />�Burlal ❑�onation �[L � �J i 9PQ � A�X'1�.. �� L�Q�
<br />_,.,.._.. . ...... . ............._ _,..____ _
<br />❑ Cramalion ❑ Enlom6men 18d. CEMETER REMATORV QR OTH�R I,pCA N CITY / TOWN STATE
<br />❑ Removal C� Olher (Speclfy) Cook Cemetery � Cook, Nebraska
<br />7,+ FilniFqnl Nn_��qMF. AN�MAILIN6AODRE55 (Sireet,_City . I 17b. Zip Cada
<br />.___..__.._..... .
<br />F'usselm�n-Wvmore Funeral Home 644 Pa�k�St. Box��6 Svracuse, Ne � 68445
<br />18. PART I. Enter Ihe cheln e1 �gry{y--diseaeee, InJurlas, or campllceliane--thel dlreclly caused Ihe deeth. DO NOT enter tz}minal eventa euch ae cardlac arrest, ' APPROXIMAT6INTERVAI.
<br />I
<br />respiratory arrest, or venir�cular fibrillation w�lhout Showinp ihe Bti0logy. DO NO7 A96pEViATE. Enter only one cause on a I�ne. Add additlonel Ilnes II necessary. �
<br />IMMEbIATE CAUSE: � onael to death
<br />I
<br />IMMEDIATECAUSE�Final „�e�. �Eta5�8,�x.0 .i.11T1'� cancer � � R701lt.rl.S
<br />diaeaseorconditlonrcaulting DUE T0, OR AS A CpNSEqUENCE OF: i onael �a dealh �
<br />In deeth) �
<br />SequenNally IIsI candNlvns, ll ro) �
<br />any,leadingtothecauselleted DUETO,ORASACONSERUENCEOF: � � � I onsettodeath�
<br />on line a.
<br />I
<br />EnlertheUNDERLYINGCAUSE . � �
<br />(dlaeaseorin�urylhallnlllated (�) I
<br />theevenmresullinglndeath) DUETO,ORASACONSEQUENCEOF: I onsettvdeath
<br />� "
<br />I
<br />(d� I
<br />18. PART II.OTHER SIGNIFICANT CON�ITIONS-Condlllons conlrlbuling to Ihe dealh but nol resulting In the underlying cause glven In PART I. 79. WAS ME�ICAL EXAMINER
<br />20. IF FEMALE:
<br />� Not pregnant w�ihin past yea�
<br />� Pregnent at llme of deelh
<br />❑ Nat pregnenl, but pregnenl w�thin 47deys ol death
<br />a Nol pregnent, bul pregnent 43 days to 1 year belore deafh
<br />❑ Unknown if pregnaN w�ih�n ihe pasl year
<br />-- -- - _�,_._ � _._� _....--
<br />2�a�D0.TE0�!N�!f1Y,. .pe t ...�1:19lE
<br />- m I
<br />22e. �ESCRIBE HOW INJURY OCCURRED
<br />22d. INJl1RY AT WORK7
<br />[] YES ❑ NO
<br />21a. MANNER OF �EATH
<br />� Natural ❑ Hqmicide
<br />❑ Accldent0 Pending Invesllgatlon
<br />1� Sulclde d Cauld nol be determined
<br />� e2c. "rL,4f;E
<br />221. LOCA710N OF INJURY • 5TREET 8 NUMBER, APT. N0. CITY/TOWN
<br />STATE ZIPCObE
<br />��r �°�` 23a. DATE OF D�ATH (Mo., Day, Yc) � 24a. DAT'� 51GNE� (Mo., Day, Yr.) 24b.TIME OF OEATH
<br />��+ `r; �� !+-Q6�-05 ��� ' m
<br />�1.�� 'Y� _. N � ...,... , _.... -
<br />'�� �� 23b. DATE SIGNED (Mo., Day, Yr.) 23c.71ME OP DEAYH ��� 24c. PRCP i '�UNCED DEA� (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAp
<br />;���; � „o '�; ._ bk _ ) �...� ��- 2 : 50 am o � 6'd m
<br />''�` �$� 23d. To the 6es1 ot my knowledga, death occurrad at ihe lime, date and placa w� 24e On 1°.: besls of examination and/or invesligalion, In my opinlon dealh occurred at
<br />�,�� �� c and du t�t�le causa(s) stated. (Signature and 7itle )• �� U ihe �:'e, date and place end due to Ihe cause(s) stated. (Signature and Title )♦
<br />�w r ._ � �/ 7 � r�
<br />n�;A4�" a r /-Z'�' �, rJ ���r%rvC�' V °
<br />:k�reri, � -
<br />25.�IDTOBACCOUSECONTRIBUTkTOTHEDEATH? 26a.HASORGANORTI55UE�ONATIONBEE�.�'�NSI�ERE�7 266.WASCONSENTGRANTE�7
<br />'��{v �:v� 4
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<br />.��,' C� YES ❑ Nq ❑ pROBAeLY � 11NKNOWN ❑ YES '�. NO _� Nol Appllca6le 1128a is Nb ❑ YES � NO
<br />����� P7.NAME,TITLEANDADDRES50FCERTIFIER (PHYSICIqN,CORONER'SPHYSICIANOPoCOUNTYATTORNEY) (Typez;Prinq �
<br />�,:,,,; Kerstin CG Beach M.D.; 88]. Mohawk St; Syracuse NE Fi8446
<br />28a. REQISTRAR'SSIGNATURE 28b. �ATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />,�;t�'��'��c �,f�hs�. A P R 12 2005
<br />OF CORONER CONTAC7ED?
<br />U YES 1� NO
<br />21b.IF7RAN5PORTATIqNINJl1RY 21c.WASANAUTOPSYPERFORMED7
<br />C' �rivedOperatar
<br />[..i'Passanger Q YE9 $' NO �
<br />CPedestrian p�d.WEREAUTOPSYFINDING5AVAILABLETO
<br />CeOther�8peci�y) COMPLETECAUSEOFOEATH7
<br />❑ YEF � NO
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