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<br />,. . STATE OF NEBRASKA '�' `�� ir;' kt fi "
<br />,z. �� ,, r=� � � "f.�
<br />WHEN THIS COPY CARRIES THE RAIS�D SEAL OF THE NEBR,4SKA DEPARTMENT OF HEAL77,�747P/J� ��1'�CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECQRD ON FILE WITH THE NEBRA�Q��i4�i�V1(i' l�# AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LE6AL DEPOSITORY FOR,,,flIT�lL (i�€C, S' s,.,,�,�' f����, y
<br />t\ , G r` ` � ' "�
<br />DATE OF ISSUANCE � ' v � ��
<br />. . . ' � 4 � �t.� e h N �_ . t �� .�,
<br />{ � + r� 5T,q� } J
<br />11/12/2010 ��i���v� l '
<br />. � � `4���'r
<br />D�P�AR 4 � � � .
<br />LINCOLN� NEBRASKA H!J � r _,
<br />�.:.. ��:�y. :
<br />STATE OF NEBRASKA -�PARTAA�N7 OF ME/U.FH ANlD HUM/�I SER1/f �{ESrrr� � I � �• ��+ j�`� " � O O3O6S
<br />CEI2TIFICATE OF DEATH . ,�'�, , �t -
<br />1. DECEDENT'&NAN� (Fl►st, Middla� Last, Suffiz} 2. SEX" � 3� -,A�E�p GEATH (Ma., DaY� Yr.)
<br />Katherine Mn Gregg Female :O�tober 25, 2010
<br />4. CITY AND STATE OR TERRlTORY, OR FOREIGN COUNTRY QF BIRTH Sa. AflE - last BUthdey b. IRJDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH{Ma, Day, Yr.)
<br />(Yn.) MOS. DAYB HQURS MINS.
<br />Holyoke, Colorado 63 December 31, 1946
<br />7. SOCIAL SECURlTY NUMBER Qa. PLACE OF DEATH
<br />50$ li�,SP191, ❑�npadeM OTHE@ ❑ Nuninp HomeJt.TC � Mospk� Faeilily
<br />8b. FACILITY-NAME (If not I�stlWtbn, Qive street and number) � pR/putpatieM ❑ DecedeM's Home
<br />�
<br />� 5a1nt Francis Medical Center ❑ ooA ❑ a�,er �Specrcy�
<br />W 8c. CITY OR TOWN OF DEATH pnclads Ziry 6o�y _ 8d. C6UN'iY OF DEAT ' :_.,_.. >;_ ..
<br />o Grand Island 68803 Hall
<br />Q �. RESI�NCESTATE 9b. COUNT'1f 8C. CRY OR TOWN
<br />u7 Nebraska Hall ' Don' an
<br />� 9d. STREET AND NUMBER . APT NO. 8F. ZIP (:ODE 9Q. i�lOE C17Y UMITS
<br />;; 316 Amick Ave. 68832 � t'ES ❑ No
<br />$ t0a. MARITAL STATUS A7 71ME OF DEATH � Martkd � Nevsr Marrled tOb. NAME OF SPOUSE �Flnt, Mitldle Last, Sufflz) H wif�, qive maideq oame
<br />� ❑ neamea, b�t:ep.�c.a ❑ wiaowaa ❑ oworeea ❑ u�noMm MarBn Gre g �
<br />� 11. FATHER'S•NAME (Ftrst, Mlddle, last, 8ulrix) 12. MOTHER'S-NAME (I�int, AMddW, Malden Swname)
<br />� John Brown Peggy Clark
<br />�' 13. EVER IN U.3. ARMED FORCES'T GNe dates of serWCe If Ybs. 14a. iNFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />� �r.s, No, w unk.► No Kim Neal Daughter
<br />� 15. METHOD OF DISPOSITION 7ia. EMBALMER-61GlIATURE 18b. L�ENSE NO. 16c. DATE (Ma, Day, Yr.)
<br />F � Burial ❑ Donallon
<br />Kevin Wood 1325 November 2, 2t}10
<br />� Cremation ❑ EMombmeM �gd. CEMETERY, CRBMATORY OR OTHER LOCA'TION CITY / T'OWN STATE
<br />❑ Removal ❑ Olhe� lsP��Y)
<br />Wespawn A9�morial Park Crematory Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADORESS (StPesk Ctly qr Tpwn, Sfatel '�7b. Lp Coda
<br />Livingston-Sondermann Funeral Home, 601 N. Webb Road, Grand lsland, Nebraska 68803
<br />ee ns rua ons an exam es
<br />1& PART 1. Enter ths {dyjln of m�. �diesaps. in)urks. a campiicatlonrMat dirocty aupd tM daaM. DO NOT mbr MrtMnN �wnb such a� cardiac amtl, ; qpPitO�OMATE IMTERVAL
<br />rospintory ansrt, or wMA�wla flbHllatlon wNhout spowinp Ma Nblopy. DO NOT ABBR6YIATE. Enhr only aw puw on a Ilm. Add addWcnal Nraa It necsssary.
<br />IMMEDIATE CAUSE: ; oncet to death
<br />IMMEDIATE CAUSE (Plnal e) Cardiopulmpnary Arrest � ; Immediate �
<br />aissass or eona�8on 1.wltinp � . . . - . . . . . . ' � . �.
<br />In 9sam� DUE TO, OR A8 A CONSEQUENCE OF: � On�et QD d�th
<br />ssyu.Mtany i�.t eonamon,, x b) HypgnrophiC Cardiomyop8thy
<br />any. la�dinp M the caus� IIStM � � � � . .. � j � . .
<br />on Iina s. DUE TO.OR A COMSEQUEI�[CE OF: .' orrst W tlwth
<br />EnbrShsINIDERlV1NGCAUSE �)Chronic Obstruetive Pulmonary Disease � � - � � � . � . � . ,.
<br />. (tlfaa�a or InJury Mat Inidated .. . � . . .
<br />u'° "'°"t°'°"'m"o k� auN'� DUE TO, OR AS A CW4SEQUENCE OF: : onnt to death
<br />`"sT d)Congestive Heart Failure
<br />:
<br />18. PART II.OTHfR SIGNIFICANT CONDITIONS�CondtUons conMbutMp to the deaEtl but not rss�tlnp In the unda�griny cwse yNen in PART 1. 18. WA8 M@DiCAL EXAMINER
<br />Chronic Renal Failure, Hypertension, Dialysis Patient CN2 CORONER CONTACTED?
<br />� �� ��
<br />� O. IF FEMALE: 21a. MANNER OF pEATN 214. IF TRAN$PORTATION INJUR 21c. WAS AN AUTOP81l PERFORMED?
<br />F � Nol pnpnaM wllhin pan year �� � " � NeW ral � NOmtckN �� DHwNOpNator . �
<br />� � W Prepna�k at tims of death ' � Pasan{Nr � � � � . � ..
<br />. V ❑ . � Acddw�f � � P�MIIn91nW�NQaNOn
<br />T � NM pn��M w�e o�� �n��,� a w a�n :. . .�. p p.e.anM s�d. we� aurorsY Farrnw�a nva�
<br />a ❑$"�° ❑�" a � ° ""�'� TO COMPLETFC/kl�E OF DEATII4
<br />� Na pnpnant, hut prepnam 43 Aays � t yepr Wtoro ueaen � o�Mr (Bp�dry►
<br />� � Unknown H P�eOnmt wHMn me P� Year � . . . . . _ . . . . . . . ❑ YES ❑ NO .
<br />� Z2a. DATE OF INJURY (Mo., Day, YrJ 22b. TIME OF INJURY 22c. PLACE OF INJURYv4t home, tarm, ttrea4 tactory. offl¢e bullding, const�ucHon ske, etc. (SpscNy)
<br />;� 2d. INJURY AT WORK? 22a. DESCRIBE HOW INJURY OCCINiRED
<br />1�- � . . � � � .
<br />[]YES Q NO
<br />22f. LQCATION OF INJURY • STR@ET 8 NUMBER, APT.NO. CITYITOWN STATE ZIP C�DE
<br />„
<br />- 23a. DA'� OF DEATH1MO., OaY. Vr.) _ _ .. _ _ _ _ _ _ _ _ Z4a: D747�SI6NED{Me. �--- - ZA6� �IML A� D�Jk�F- "--- - _. . _ __ _ _ _ -_ - - - €
<br />� w 3� �� October 26, 2010 07:25 AM
<br />��� 23b. DATE SIGNED (Mo., �ey, Yr.) 93c. TIME OF OE4TH ���} 24c. PRONOUNCED DEAD (Mo., �y, Yr.) 14d. TMAE PRONOUNCED DEAD
<br />< Z October 25, 2010 07:25 AM .
<br />� 3d. To M� bat ot my knowl�da�, tlarth occnmd at fh� qiM. dab and Waa . � .
<br />� $ 2M. On ths basis of �umMalbn andlw Nwestipatlon, io my opNOn tlNth oecumd rt -
<br />F and �w to th� qup(s) tfabd. 4$Ipn�taq arM TW9) � Slw dme. daN and D�e�+ antl aw to Ms awe(t) sbtsd. (Sqnatwa ane fld�)
<br />� u Sarah Carstensen, Hall Deputy County Attomey
<br />25. DI T BACCO USE CONTRtBU E TO CEATM? 28a. HAS ORGAM OR T�SUE NATION BEEN CONSIDERED? 28b. WAS C N N D?
<br />YES �] NO PROBABLY UNKrWWN � YES � NO NotAppUcable If 26a Is NO YES ❑ NO
<br />e or
<br />Sarah Carstensen, Hall Deputy Counry Attomey, 231 S. Locust, P.O. 8ox 36T, Grand Island, Nebraska, 68802
<br />28a, REGI8TRAR'S SIGNATURE YBb. DATE FIFED BY REO�TRAR 11Mo., FNry, Yr.)
<br />October 28, 2010
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