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STATE OF NE6RASKA
<br />VYHEI�I THIS COPY CARRI�S 7`H� RAISED SEAL OF 7'H�' NEBlL45KA D�PARTMENT OF HEALTH AI�J�Ilihl�4 S�'RVIC�S, 77' CERTIFIES
<br />THE BEI.pW TD BE A TRUE CC7PY OF THE ORIGINAL`itE'CORD ON FILE WI1`H THE NEBRAS(�4'� 1�Nj�f�l� b�F F�EALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH I5 THE LEGAL DEPO5IT�RY FOl7 ,�'l`A, L\ L�.`�R�S'`' � r-�� 1 ;� �,
<br />DATE OF ISSUANCE /�`��� � , �J '� .
<br />5��.�Y' �0��'�7.' v� :, . �, „/� .
<br />AuG2� 2oto � 201008776 ���A" � ��A�;�; .
<br />D�PfA'l��M� C7J' InF���`1�1� '..., ." � .� _
<br />LINCOLN, NEBRA5KA MI,JM�1 N� SEl7•VI�,�: � :!;; a';; . `
<br />STATE O� N�BRASKA -�PAR7M�NT OF H�ALTH AND NUMAN SERVI��S ^.:'� °_,- c� �,� �
<br />C TI ICAT� OF D '���' `���-'Q�
<br />1. 4ECECENT'S-NAME (Flrg� Middlo, L86t, S4fl7X) 2. SEX :� a. oqr,� pf oen,rH �� Day�Yf.)
<br />Charles Robert Frith Male Au ust 9, 201D�
<br />A. CITY AN� 57ATE OR TERRITORY, OR FOREIC3N GOUNTRY OF 61RTH 5d. AGE�l.ast 6lrthday 3b. UNf1Eft 1 YEAR Sc. UNOER 1 OAY 6. DATE OF BIRTH (Mo., Dey, Y�.)
<br />(YfS.) MOS. �AYS HOURS MINS.
<br />Rogers, Arkansas 77 June 30, 1933
<br />7. SOCIAL SEGURITY NUMBER Bd. PLACE tlF DEATH
<br />443-30-4963
<br />PI7AL: � Inpatlent OTHER: ❑ Nursing HomeILTC � Hospice Facllfty
<br />Bb. FAqL17Y�NAME (If naY Institutlon, glve streM and num6er) [� ER/Outpatlent ❑ OecedenYs Hame
<br />BryenLGH Medical Center East [] oon [] anansPec�ry�
<br />ec. CITY OR TtlWN OF DEATH (Include Zip Code) � 8C. CtlUNTY QF 4EJ+TH
<br />° a+ Lincoln 68506 Lancaster
<br />8a. RESIqENGESTATE 8b. COUN7Y 9C. CITY OR 7C7WN
<br />7
<br />u ' Nebraska Hall , Grand Island
<br />S.
<br />a 8d. STI2EET ANp Nl1M8ER 8e. APT. NO. 9f. ZIP CODE 9g. INBIqE CITV 41MITS
<br />�e A803 Deva Drive 88601 � Yes � No
<br />r
<br />� 10a. MARITAL STATUS AT 71ME OF DEATH � M9rd0d � Never Married 104. NAME OF SPOLISE (Fifet, MItltl12, L38t, SU}f1x) If wih, give maitlen nama.
<br />❑ Married, nutsepareted ❑ wiaowed ❑ Dwarcea � unknown BesSje E 8akef
<br />�
<br />� 71. FA7HE1�'S-NAME (F'I�St, Mlddle, Last, SufliX) 12. MDTHER'9-NAME (F1rst, Mlddle, Maiden SurnBme)
<br />v Jose h Lewis Frith La Vaw n S. St e henson
<br />m 13. EVER IN U.S. ARMED FORCEST OIVO tl9M5 M58rv1C4 N YeB. 14a. INFORMANT-NAME � � w~ � 1A6. RELATIONSHIP TO DECEPENT
<br />h
<br />�vag,NO,orunK.� y� 2/1954 2/1958 Bessie E Frith Wife
<br />16. METHtlD OF DISPOSITIDN 16a. EMeALM i6b. LICENSE NO. 16c. nA7E (Mo., Day, Yr.)
<br />�au�a� Qoa.,�non /�p r C S�LZ�2�10
<br />�cremativn C]E.nancmem •
<br />� �•mova Qomery9pecty� 76A. CEMETERY, CREMA70RY OR OTHER L6CATION CITYlTOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17e. FuNERAL HOME NAME AND MAILING AqpRESS (Strart, Ciry or Town, StaM) 77b. 7Ap Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />Butherus-Maser & Love Mortuary, 404Q A Street, Lincoln, Nebraska �or 6851q
<br />CAUSE �F D�Al'FI See instructinns and examples)
<br />18. PAR7 �. Ent�r the ahaln oY'evarts- dleeaaea, InJuries, or complicatfons-cnat 01nMy aau�ed tM daath. CO HO7 antertaminal rvw�rc cuch as cardiac arrext, � qPPROXIMATE INTERVAL
<br />fesp�nrcnry CReat, er venM�uMr Ilbrltlatlon wkhou[ ehowinq ih� atialapy. �O NOT AbAR��TE. EeNx ordy one eeuee on e&�e. Add eddilivnel linas if mceasary.
<br />IMME�IATE CAUSE: ; OtlSCttO tl08th
<br />IMME6IATE CAUSE (Flnal �
<br />disaasa ar condition resulting a) .e �
<br />In deatn) � � ( �
<br />oUE To, oR As A CONSEOUENCE / O 1 F: I onset W death
<br />8equendally Iist Conditiona, If �) ' / „ _ �/ �y-., , - ( / '
<br />eny, leadmg ta tne ceuse Ifsted ���� GA/�. �/���'(. ��/(/LJ:.�
<br />011 IIl10 0. DUE TO, OR AS A CONSE �NCE DF: � on ei to tleain
<br />Enterthe UNpERLYINO CAUSE �l 1 Y7'y 1 �S �� �„�, f �
<br />(dlaease or InJury that INtlated � �
<br />the events resulting in death) nUE T6, oR AS A CONS QUENCE OF: set to death .
<br />LAST
<br />d)
<br />19. PpR7 II. OTHER SIpNIFICANT CON�ITIONS-Condttlona contributing to tha tlf8t11 hut nM I'esultlnq In tBe untlerlytnq CBUSe qiven In PART I. 19. WAS MEpICAL E%AMINER
<br />OR CORON�R CpNTACTED?
<br />Q YES �p
<br />!" �
<br />W aa. IF FEMALE: 21a. MANNER OF DEA7H 21n. IF TFtANSPOItTA710N INJURY 21c. WAS AN AUT� SY PERFORME07
<br />F []N�fipregnantwlmin pastyear �Naturel ❑ Homlclae ❑ DHverlOperamr �] Yes
<br />� ❑ Pregnant at nme nf destn � Accident �f Penalnq Investiqatlon ❑ Passenqer
<br />� 21d. WERE AUTOP3Y FINDIN�S AVAILA6LE
<br />❑ N� preqnem, Eut preqnant wltMn 42 tlays of deatn ❑ 5UICIde ❑ COYId IIOt ba dgtgn111PeA ❑ pedesman TD COMPLETE CAUSE OF OE4TH7
<br />�' ❑ Not preqnant, but preynant 43 days to 1 year bafore death ❑ Other (Speciry) .[] YE5 C] No .
<br />�� �UnknovrnHpregnentwhhlnthepastyaar .
<br />� 22a. OATE OF INJURY (Mo., �8y, Yr.) 22b. 71Mf OF INJURY 22a PLACE OF INJURY-At home, farm, street, factory, office bWldinfl, ConsG'uCdOn Site, etC. �SpeClfy)
<br />a
<br />t] m
<br />m
<br />m 22d. INJURV AT WORK? 22e. �ESCRIBE HOW INJURY OCCURREO �
<br />D
<br />�" ❑ YES ❑ NO
<br />22f. LOCATION OF INJl1RY -STREET d� NUMBER, APT. NO. CITYITOWN STATE ZIP COOE
<br />2aa. DA7E pF �FATH (Mo., Pay, Yr.) � 248. PATE SIGNED (Mo., �ay, Yr.) 246. TIME OF OEA?H
<br />Td '
<br />aW ��� m
<br />� p
<br />a �' � 23b. OATE SI�NE (Mo��By, Yr.) 23c. 71ME OF bB'ATH .A! } O Y4c. PRONOUNCED DE40 (Mo., Day, Yr.) 24d. TIME PRONOUNCE4 DEA�
<br />� y' 1 Ss�}
<br />� J�.' �� s 1 a171 �N�,� Rl
<br />O O O
<br />" V 23d. To ths 6e9t of my knOWledge, death OCCll�retl 9t thE tIIriB, date ana p�ace � w 2 2va. tln me bes�s of examinatlan andlor Investlgation, in my opinlon dea[h accurred
<br />� d and due to the cause(s ta .(Sipnature and Tmr) �' p � at th0 time, d8t6 911d p18Ce elltl d110 t0 ttl¢ C2tISE(S) St3t2d. (SIql78t111'¢ 311d Title)
<br />H� �� FQU
<br />� U C
<br />25. Dld 708AGC0 USE CON7RIBU7� TO UEATH7 76a. HA tlRGAN DR TISSUE DONATION BEEN GON3IAERED? 266. WAS CONSENT GRANTeD?
<br />Q YES ❑ NO Q PROBABLY NOWN YE5 [] NO Nok Applica6le If 28a Is NO [,� YES O
<br />\ 27. NAME, TITI.E AMD ADDRES$ OF C�RTIFIER (PHYSICIAN, PHV$IGIAN A$SISTAI�T, CORONER'3 PHYSICIAN QR GOl1NTY ATTORNEY) (Type ar Print)
<br />�' 1� ^�'� {KD ��1 l n � r
<br />28a. RE6ISTRAR'S BIGNATl1RE 28h. �ATE FILEU BY REGI57RAF2 (MO., �dy, VG)
<br />P d. Au� x $ �o,o
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