|
STATE OF NEBRASKA .; � : �'�,; ..
<br />�' '`',
<br />WHEN THIS COPY CARRIES THE R.4ISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTf�:;�A'f�►�11� ��+�'�5;�.2�",CL�RTIFIES
<br />THE BElOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAS(�A"D A4J2fiI �B�`A���H�4AfW
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR �"1` f�'��O `� �i' �'' `� ,��
<br />'`� •�.� +�� '•�:,�., t�x
<br />DATE OF ISSUANCE � .. �y�
<br />" ��n � r ,
<br />12/0712010 � 01 i Q i� 3 8 . A�"��. R,��� `�«� �
<br />�E ;- ;,r
<br />LINCOLN, AIEBRASKA MU1�,4P� .�� �, : ; , �,
<br />�. + ' u �, t �'', c� ' ,,,�
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AWD HUMAN SERVIGF�S ` r� �i� j.� � �,' .�+� ,,,�j 0 03519
<br />CERTlFICATE OF DEATH � J T ' ' • • �. � cy� -�
<br />1. DECEDENT'S-NAME (FIrsR Middle, Las4 Suffix) 2. SEX � �Y: ATE OP DE/�,TH (Mo., Day, Yr.)
<br />Karen Lea Hil{i as Femaie ' Nov�m"ber 26, 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN GOUNTRY OF BiRTH Sa. A(3E � Last Bkthday . UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF QIRTH (Mo., Day, Vr.)
<br />��•) MOS. DAYS HOURS MiN3.
<br />Noble, Illinois 70 November 26, 1940
<br />. SOCIAL SECURITY NUMBER 8a. PLACE OF pEATH
<br />324 �(] Inpatierrt Q�HER ❑ Nualnp Home/LTC � Hosplce Facllity
<br />8b. FACiIITY•NAME pf not I�stiqrtlon, give strwt and number) ��/p�ue�t ❑ Uecada�t's Homa
<br />�
<br />� 2323 Beliwood Dr. L7 �A � onar►ls�s�' home - .
<br />� Bc. CITY OR TOWN OF DEA7H (includa Zip Code) ed. COUNTY dP DEATH
<br />c Grand Island 68801 Hall
<br />� 9a. RESIDENCE�STATE 9b. COUNTY 9c. CRY OR TOWN
<br />w Nebraska Hall Grand Island
<br />� 9d. STREET AND NUMBER 8e. APT. NO. 8(. ZIP C�DE 8q. lNSIDE CRY LINpT3
<br />;, 941 S. S camore 68801 � ves Q No
<br />� 70a. AAARITAI STATU8 AT TIME OF DEATH � Marrled � Naver Marrled 10b. NAME OF SPOUSE (Firat, Middls, WsR Suffix► H wHS, gNe maiden name
<br />� ❑ Mamed, but separated ❑ Widowed ❑ Divoroed ❑ UMcrrown ��mes Nilligas
<br />� 11, FATHER'S-NAME (Fkst, Middle, I.ast, Sufflz) 12. MOTHER'S-NAME �Fint, Middle, MaWen Surname)
<br />Karl Henry Myers Beulah May Johnson
<br />E 1S. EVER IN U.3. ARMED FORCE8? Give dates of seMce tf Yes. 14a, tNFORMANT•NAME 14A. RELATION6HIP TO DECEOENT
<br />$ �ves, No, or unk.) No James Hilli as Husband
<br />°� 15. METHOD OF DISPOSITION 76a. EMBALMER-3IGNATURE 16b. LICENSE NO. 16c. DATE (Mo., D�y, Yr.�
<br />F � s�nai ❑ Donatbn Daniel D NaranJo 1071 December 2, 2010
<br />❑ Cremation Q Ernombment �gd. CEMETERY, CREMATORY OR OTHER LOCATION ClTY I TOWN STATE
<br />❑ Removsl ❑ Othsr (Specity)
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />i7a. FUNERAI. HOME NAME AND MAN.INti ADDRESS �SVee4 Clty or Town, State) 17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />ee nstru ons an exam es
<br />7!. PART I. EM�r the duln ot avantr 4lw�ses.l�uAw, a complla�ions�Mat tlinctly cauwd tha d�ath. DO NOT waer tarminal avana sucA u csrdisc arrest, ; AppROX1AAATE INTERVAL
<br />respintory amst, or venerleular flbhlbtion without shaw1n91he etialopy. DO NOT ABBREYIATE. EMSr onty one cauw on a Ilne. Add aaGlUOna1 Haes I[ neoesary.
<br />IMMEDV0.TE CAUSE: � omst to death
<br />IMMEDIATE CAUSE (Final a) Anemia � � 6 Months
<br />dlpaa� or conAWOa owlting � � � -
<br />M d°° DUE TO, OR AS A CONSEQUENCE OF. ; onset to death
<br />SequaNfaly IIN condklons, n b► Metastatic Thyroid Cancer � 't Years � �.
<br />any, Nadinp to tM cauae Iisted .� � �
<br />on nne a. DUE TO, OR AS A CONSEQUENCE OF: t nacet W death
<br />Entef th� UNDERLYING CAUSH C ) � � � �
<br />(disease or InJury that InNiateO �
<br />the evenu rewltlay in death► DUE T0, OR AS A CON9EQUENCE OF: : omet to dsath
<br />LAS7 d) . i � .
<br />18. PART II.OTHER SIGWIFICANT CONDRIONS�Condipons corkrlbuNnp to the dwth but not resulGnp in the underyinp cause given in PART 1. 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTEDT
<br />� �� ��
<br />� 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 27c. WAS AN AUTOPSY PERFORMED4
<br />� � Not we4�rt wtihin past vear � � ��Natural � HHOrmmciM � DrharlOPerato� � YES � NO
<br />v � PropnaM attime of Aeath � A�eldaM � Pendinp Inwstlyatlon �� Paaenper
<br />� Na pregnaM but prepnaM wkhM 42 tlays ol Math � PeMstrian 21d. WERE AUTOP3Y FIN�NGS AVMLABL
<br />� � BWCide � CnuW not ba tlaurmineu TO COMPLETE CAUSE OF DEATH?
<br />� � Pbt propnant, but propnant 4t tlays to 1 year betore deaM � Other (Speciy)
<br />� � Unknown N preqnaM wRhln tiw past year Q YE$ ❑ NO
<br />� 22a. DATE OF INJURY (Mo, Day, Yr.) 22b. TIME OF IpWURY 22c. PI.ACE OF INJURY•At homs, hrtn, streey hctory, oHice bulldinp, eonsWetion slte, etc. (Speelfy)
<br />t3
<br />.� 22d. INJURY AT WORKT 22e. DESCRIBE HOW iNJURY OCCURRED
<br />i�-
<br />� YES ❑ NO
<br />22f. LOCATION O INJURY • STREET B NUMBER, AI'T.NO. CITY/TOWN STATE ZIP CQOE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. p/�TE SIGNED (Nc., Day, Yr.} 246. TIME QF DEATH
<br />B W NoVember 2$, 2Q10 - - � _ � � -
<br />�� Y 2Sb. DATE 5tONED �Mo., pay, Yr.) 2SC. tIME OR DEATH �� k � 24c. PRONOUNCED OEAD (Mo., �y, Yr. ��d. TIME PRONOUNCED OEAD
<br />� November 30, 2010 09:38 AM d` o
<br />. To d» bsat of my k+rowNdy�, defth oceurwd at d» iN�w. d� afld plap y�e. On tM basls of examMadon and/or Invuqpadon. M my opinbP tlwG� aoWmd at
<br />$� and dw to the causels) sGteA..�Slpnaturo and Title) � $� pfe time, date and place anA Ow to Ehe cawsls) aprtaA. f$�W�aluro md Tttk)
<br />~ � Jared Pehrson, MD ~ � s
<br />25. DID tOBACCO USE CONTRIBUTE TO TNE DEATN4 26a. HAS ORGAN OR TISSUE DONATION BEEN C IDERED? 26b. WAS CONSENT GItANTED4
<br />(� YES [] NO � PROBABLY [] UNKNOWN ❑ YES � NO Not Appl�able if 26a is NO VES � NO
<br />, ) ype or rrt
<br />Jared Pehrson, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803
<br />28a. RE(313TRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yra
<br />December 6, 2010
<br />
|