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STATE OF NEBRASKA
<br />WHEN THI5 COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPAR
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WI
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS TME LEGAL DEPE
<br />DATE OF ISSUANCE
<br />�u� � 2 20�0
<br />Madison, Nebraska
<br />7. 30CIAL SECURITV NUMBER
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<br />LIIVCOLN, NEBRASKA . s�: a /I�M�1 S R`V�' -
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<br />� STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND WUMAN 8EftVIC�� l �. '�� fl.�$�
<br />C T OF T
<br />. 1. DECEDENTS-NAME (Finq Mk1dN,� Las4 Suffix) � � � 3 � , _ ..' , , _.. .
<br />Norman Phillip Blank
<br />4. CIIY AND STAT6 OR TERW7'ORY, OR FORffIGN CWJNTRY OF BIRTH
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<br />CERTIFIES
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<br />8. OATE OF��BIR7N(Ma, D�
<br />February 21, 1939
<br />507-42-5183 HQ$P1ISL: � Inpatknt Q'[yEg; Q Nmsing HomeILTC
<br />6b. FACILITY-NIUAE (1/ not InsNtudon, yive sWN and number) � � � ERlOutpatlent �� DecedsM's Hom�
<br />Saint Francis Medical Center � °O0i �
<br />8e. CYTY OR TOWN OF DEATH pnclude 21p Cods) � 8d. COUNTY OF DEATH
<br />Grand island 68803 Hall
<br />9s. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN �
<br />Nebraska Hall Grand Island
<br />� Hospica Facllity
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<br />9d. STREET AND NUbIBER 9a. APT. NO. 8L 21P CO�E ,. 9g. IM81DE CITY LiM1T8
<br />1310 Mansfleld 68803 �l Y� ❑ �
<br />10e. MARITAL STA7118 AT TIME OF DEATH �� Marted ❑ Nevmr Martf 10b. NAME OF SPOUSE (Flrot, Middle, Laat, SuMx) p wi/e, give�m�itlen name. �
<br />❑ Married but sapuated � Wldowed ❑ Dlwrcetl ❑ Unknown Nan Karel Fravel
<br />11. PATHER'3•NAME (Fint, MMdle, Last, Suftix) � 12. MOTHER'3-NAME (FInR Mfddls, Maldrn Sum�me) �
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<br />6a ACE-{.adt �hhday� 6D. UNDER 1 YEAR Se. UNDER 1 D�
<br />. (Yra.� ��. MOS. DAY3 HOURB MII
<br />7�
<br />� Ba. PIAC60F DEATH � �
<br />Frank Biank Am�
<br />73. EVBR IN U.S. ARMED FORCEST Gtva datas oi seMcs H Yas. 14a INFORMANT-NAME '
<br />�res, rb, o. u��.> Yes Nan Karel Blank
<br />16. METHOD OF D18POSITION 18e. EMBALMERSI6NATURE
<br />� 0°onaN Not Embalmed
<br />�cnm�tlo� pemanum.�e �
<br />� iamovat Qqtn�sp�eiy� 18d. CEINETERY, CREMATORY OR OTHER LOCATION .
<br />Centra! Nebraska Cremation Services
<br />17a PUNERAL HOME NAME AND MAIIINCi ADDRESS (Stroet, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand lsland, Nebraska
<br />IMMEDIATE CAl
<br />IMMEDL4TE CAUSE (Flnal ; �'
<br />dis�ase or ¢andldon resuking . a)
<br />in d�ath)
<br />. � - DUE TO, OR AS
<br />SequenUally Ifst conditfena, M� bj �
<br />e�ry. Isadf� to the cause ItsNd
<br />O° 1M° °' � OUE TO, OR AS
<br />opy. DO NOT
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<br />JENCE OF:
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<br />lENCE OF:
<br />CITY/TOWN
<br />Gibbon
<br />any ons e�w� on � Bna Aal �tlCkbml lins. H mcNwry.
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<br />Enror Ms UNDERLYING CAUSE �) �
<br />(dlseass or Injury tliM iniHatad�
<br />tM ewnh rssWtlag in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
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<br />78. P(IRT p. OTHER SIGNIRICANT 1
<br />aonMbutf te tlro deeth.bu! rwt multlng. in ehe undwlying cauw yiven in PART L�
<br />7 �Y�
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<br />W Z0. IF FEMALE:
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<br />❑ Not pregnaiN wlthi� p»t y�ar
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<br />� ❑ Prognmt at dme of dealh �
<br />❑ Not prepnaM. twt prognant MtMn 12 days of deap� �
<br />� ❑ Not prognanF propnant 43 daya to 1 ysar beTore dea
<br />� ❑Unknown HqropnaMwithin th� past year
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<br />� 21 . MANNER OF DEATH 216. IF TRAN3PORTATION
<br />NaWral ❑ Homldde � DriverlOpsntor
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<br />❑ AacideM ❑ Psnding InvsatlQation � ❑ Pasaenper
<br />❑ Suiclde ❑ Cwltl not bs determfrnd ❑ p�desMan
<br />❑ Ofher (Specity)
<br />74b. RELATIONBHIP TO DffCEDENT
<br />Wife
<br />18c. DATE (No•. DaY. Yr.) .
<br />June 17 2010
<br />STAIE •
<br />Nebraska
<br />17b. Zip Coda � .
<br />68801
<br />� APPROXNIATE RJTERVAL
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<br />' onsettodeaM
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<br />� onsat to deatb
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<br />; onset ro aam
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<br />. 10. WAS MEOICAI EXAIAINER �
<br />OR CORONER CONTACTED7
<br />❑ YES � NO
<br />27c. WAS AN AUTOPSY PERFORMEDT
<br />❑ YES �0
<br />21d. WERE AUTOPSY FINDINGS AYAILqBL!
<br />TO COMPLETE� , C ( AUSE OR DEATHT
<br />❑ YES L NO
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<br />� � 22�: OATE OF iNJURY �Mo., Day, Yr.) 22b. TIM@ OF INJURY 22c. PLACE OF INJURY�At homs, farm, �t, factory, oHice bWldiny, consGUCdon Nt�, stc: �8p�cliy)
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<br />m 22tl. INJURY AT WORK4 12�. DESCRiBE HOW iNJURY OCCURRED �
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<br />� ❑ YE$ � ❑ NO . � . � . .
<br />T2L LOCAi10H OF INJURY - STREET 6 NUMBER, APT: NO. CITYliOWN � STATE ZIP CODB
<br />23a. DATE OF DEATM (Mo., Day, Yr.) � � Z 24a. DATE 81(;NED (Mo., Day, Yr.) � Z{b. TMAE OR DlATH .
<br />T�
<br />' June 16 2010 � � � ..��z . � m
<br />� 236. DATE SIGNED (MO., Day, Yc) 23c. TINE OF DEATH . 24c. PRONOUNCED DEAD (Mo., Day, Yc) 24tl. TIME PRONOUNCED DEAD
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<br />JO June 17, 2010 22227 P.� �u�,a� m
<br />m V 2. To bsst oT my knowledpe, ds�th occurtetl it the Nme, dMe arM.placa ��� 24e. On the baais ot szaminaHon andlor inwsqgatlon, in mp opinion dqM xcurted
<br />� p w to ths caute(s) steted. (Sipnatun �aild Title) ,� � � at the fim�, date and placa and dus to th� cause�t) sUled. (Sipnaturs and ittle)
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<br />26. DID BAC USE CON RIBUTETO THE DEA � 26a. HAS ORCdAN OR TISSU DONATION BEEN CONEIDERED? 28b. WAS CONSENT 6RANTED9
<br />❑ S� ❑ NO � P1�8A8LY ❑ UNKNOWN ❑ Y@S �� NO Not Appllaabls I( S8a Is NO ❑ YES NO
<br />]7. NAME, ittLE AND A SS OF CERTiF1ER (PHYSIGAN, PHY$ICIAN AS:iISTANT, COR ER'S PHYS�CIAN OR COUNTY ATTORNEI� (Typa or PrqM) �
<br />John A. Wagoner, M.D., 800 Alpha, Grand Island, NE 68803
<br />26a REOIS7RAR'9 SK3NATURE ' 1 � 28b. DATE PILED BY RE(iISTRAR (MO., Dyr, Yc) .
<br />�J • �(UN Z 1 2010
<br />18b. LICEN8E NO.
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