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<br />StATE OF NEBRASl�A . - `
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBR,4SKA DEPARIMFNT Of Tt ,! � �'J► ,, S;�R►(,f�ES, I7' CERrIf7ES
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<br />THE BELOW TO BE A TRt/E COPY OP tHE ORIGINAL RECORD ON FILF WITH THE N `� , NEALTN AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHIGH 75 THE LEGAL DEPOSI7Y� ' � t �� �` •,`_ -
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<br />DATE OF ISSUANCE 4 �� ~ �� �� 4
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<br />ov2oi2o�� 2011U2840 °� � �� , .:� � �� � � ° ��
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<br />LINCOLN, NEBRASKA ' pd � �� . ,� , �
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEftY�� ����i�� ,` �� . � � �O'I BO
<br />CERTIFICATE OF DEATH - � �...���:->,� * �` '�
<br />.�„ .:.
<br />1. DECEDENT'S-NAAAE (Flrst, Mlddla, Last, SuffUc) 2. SEX '.� ,�� � TH (Mo., py�y, Yr.)
<br />Donald Thomas Brooks Jr Male , �����„'J� ritii""alfy"14, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH . AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 7 OAY "B.'DATE OF BIRTH (AAo, Day, Yr.)
<br />��•) MOS. DAYS HOURS MIN3.
<br />Grand Island, Nebraska 51 June 6, 1959
<br />7. SOCIAL SECURITY NUMBER 8a. PtACE OF DEATH
<br />506-84-1134 HOS RAL � Inpadent 9THER [] Nursing Home/LTC � Hoapice Facility
<br />Sb. FACILITY•NAME {If �rot Ir�tltution, gNe street and number� � ER/Outpatient � Decedent's Home
<br />�
<br />� 1602 Ando Ave ❑ �oa ❑ ocner �speciry)
<br />� CITY OR TOWN OF DEATH (Iaciudo Z� Coda) id. COUNTY OF DEATH.
<br />o Grand Island 68803 Hall
<br />� 9a. RESIDENCESTATE 9b. COUNTY 9c. CITY OR TOWN
<br />Z Nebraska HaU Grand Island
<br />� 8d. 3TREET AND NUMBER . APT, NO. 9L ZIP CODE
<br />Og. INSIDE GTY LIMITS
<br />a 1602 Ando Ave gggp3 � v�.s ❑ No
<br />.� 10a. MARITAL STATUS AT TIME OF DEATH � M�rried [] Newr Marrlad 10b, NAME OF SPOUSE (Pint, Middla, Last, Suffix) If wife, 9Ne maidan nama
<br />� ❑ Married, but sepanted ❑ Widowed ❑ Diva�ced ❑ un�ow� �rolyn �OS6 hine �1l@tOVIC1C
<br />� 71. FATHER'S-NAME (First, Middle, Lasy Sufflu) 12. MOTHER'S•NAME (First, Middie, Malden Sunwrtie)
<br />� Donald Thomas Brooks Sr Marilyn Holder
<br />E 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMAN7•NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ �Yes, No, or unk.� No Carolyn Brooks Wife
<br />�' 15. METHOD OF pISPOSITIpN 16a. EMBALMER-SIGNATURE 9&�. UCENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />� � Burlal � Donatlon
<br />Matthew T. Myers 1411 January 18, 2011
<br />❑ Cremation Q Eatombment ��. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Remowl � Other (Speclfy)
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City w Towo, Stata) 17b. ZI Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />se �nstructions an exam es
<br />7!. PART 1. EMer ths shain of evenfs--tlbaaaes, InJurles. or coiapNCatipn�•lhat diraqyr qup� q» �nry. pp NOT a�r brminN waMs such as arNu amst, � � : pppRQX�MATE (NTERVAL
<br />respiratory arrest, or vantrkular fibrll�ation without ahowinp the eGOloyy. DO NOT ABBREVIATE EMer onty one cause on a IMa. Adq adtlpional Wws Ff necesary. �
<br />IMMEDIATE CAUSE: ; onsot Eo death
<br />�MMeowre cnus� �F��m e) Metastatic Bladder Cancer ; Years
<br />dissasa or condkioo resuking � . .
<br />x� dwtn► DUE TO, OR AS A CONSEQUENCE OP: ; onset to death
<br />SeqwMlatty ttat condltiona, �r b) Cyclophosphamide Exposure � � � � � � � � ? Years � � � -
<br />�y, i�moo so me aw. xs�a
<br />on Iine a.
<br />DUE TQ OR AS A CUNSEQUENCE OF: ;,aref b tlwth
<br />EMertheUNDERLYINGCAUSE �)wegeners Granulomat0.sis . � . � . �_ . � . � . . � . � ��� - -�
<br />� (dissaw�orinlW'Yffiatiniqated � . . . � . � . . . . � � � . . .
<br />rn� events resulHop in dsath) DUE TO, OR A$ A CONSEQUENCE OF;
<br />usr d) � onsot to d�th
<br />78. PART II.OTHER SIGNIFlCANT CONDR10N3-Condltio�x contrqwUny to the death but not rowltlng in the underlyinp cause piven in PART I. 19. WAS AAEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />W ❑ YE3 � NO
<br />u, 0. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERfORMEa?
<br />. � � � Not prepmnt wlthin paat yoar � � NaturW � Homicida � � D�lOpentor � �
<br />� U � PrepnaM at Hme oi deaM � . . � p�q�nt � Pandinp MvasGpatlon ❑ Pamrper � ❑ YES � NO �
<br />� � Not prepnant, but Drepnam wlthin 42 days of dwtb � Padeafflan 21d. WERE AUTOPSY FINDINGS AVAILABL
<br />� Suicida � CoWe nM be dstermined TO COMPLETE CAUSE OF DEATHI
<br />. � . � Not prepnant� but proYmM 43 tlari to.1_rix be�9n dath . . . - � 9Nwr{SPeclfyl- . . . . �
<br />� Unknown if prepnaM wiMin the pasi y�ar � � . � � pe � YES � NO �
<br />� 22a. DATE OF INJURY (MO., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJtH2Y•At home, farm, street, factory, office buNdinp, construcNOn site, etc. (Specffy)
<br />0
<br />u
<br />� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />� p ves ❑ No
<br />22f. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITYfI'OWN STATE ZtP CODE
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<br />23a. DATE OF DEATN (Mo., RaY� Yr.) -- _- _ y Y4a. QkTf SIGNEO (Ad3., 6iy, YP.j :-- i6. YtN1E bF bEATH
<br />� January 14, 2011 � � W
<br />��� 23b. DATE SIGNfD (MO., Day, Yr.) 23c. TIh1E OF DEpTH �� 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD
<br />�!� Z Janua 17 2011 09:49 AM � d<_
<br />E� � �d. To the beat of my knawlsdpo, tlaath oaurred at the time, date and �plaq � � TAe, On tM baela of examination antl/or Mrvestlyatbn, M my opNqon death oecumd rt . � �
<br />o a i M tl u a t o M e c a u s o � s) s q q d. ( S i p n a t u re a n d T I t M). � 8 z� -
<br />�o � � o o V� th6 tlme, Aab antl placa and dw to the awe(a) ahtatl. (Slpnatme anC TIN�) �
<br />Travis S. Hageman, MD � o-
<br />0
<br />25. DID TOBACCO USE CONTRIBUT TO'fhE DEATH? �a. HAS GROAN OR Tt85UE 00NA N BEE CON�DERED't 26b: WAS CtfNSENT t9RRPF�'EDT _'.
<br />❑ YES � pl0 ❑ PROBABLY � UNKNpWN
<br />0 YES NO Not ApPlicable 1f 2ia ls NO YES [] NO
<br />' yr � o )
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 � -
<br />28a. REGISTRAR'S SIGNATURE 28b. DATE FILBD BY REGISTRAR (Mo, Day, Yr.)
<br />January l9: 2011
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