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STATE OF NEBRASKA
<br />WHEN THIS COPY GARRIES THE R,4ISED SEAl. OF THE NEBRASKA DEPARTMENT OF HF.ALTH �1Uf3'•%7()I�l'A�1h,S RVICES, IT CERTIFIES
<br />THE BELOW TO BE' A TRUE COPY OF THE ORIGIN/�L RECORD ON FILE WITH THE NE8J�.4SKA ��E*�I�R'7'h,l�N� y AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE L�'GAL DEPOSITORY FOR ��i,'ITi�L` EGORDS., 4, r
<br />� �4 �/Y� '�. .' 4�� , ,.
<br />DATE OF ISSUANCE iE,)
<br />����' . ..a ., � }
<br />J U� 2 G Z O 1� • S'�`'A�tLEY S COOPER �•: °„y �
<br />D�P`�RTM A!1(C3; � ,
<br />LINCOLN, NEBRASKA 2 0�.10 3 3� 3 H�,� � SERVIG�S '.<,' a� :
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<br />3TATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES `� �., '`� �-�`' .
<br />GERTIFICATE OF DEATH � 0..r.� V O O 3
<br />1. DECEDENT3•NAME '(Flreb � Mlddie, Last, � SuRlx) 2. Sp( 3. DATE OF DEATH (Mo.; DSy, Ycj
<br />4. CITY AND STATE OR TEPRITORY, OR FOREI6N COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL 3ECURITY NUMBER �
<br />508-48-2482
<br />Bb. FACILITWNAME (Ii not IneUtudon, give atreet and number)
<br />302 West 4th Street
<br />8c. CITY OR TOWN OF ➢EATH Qnclude Zip Code) �
<br />9a. RESIDENCE-9TATE 1 8b. COUNTY
<br />8d.8TREET�ANO NUMBER
<br />6e. AQE-Laet BlrNdey Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 8. OATE OF BIFfTH (MO., Day, YcJ
<br />(Yra) MOS. DAY3 HOURS MIN8.
<br />69 Dec. 16, 1940
<br />e�. PucE oF oEnrH - - - - _ - - _ .
<br />A
<br />HOgPITAL;, ❑ InpaUant 9Sfl€H: ❑ Nureing Home/LTC ❑ Haaplce Facllily
<br />❑ �uou�aaam IADaCetlenYa Home
<br />❑ DOA ❑ Other (9pecf(y)
<br />� � � � 8d. COUNTY OF DEATH
<br />9a CITY OH TOWN � .
<br />r
<br />8e. APT. NO � BL ZIP CODE 8g. INSIDE CITY LIMRS
<br />LQ/17S �'YE8 ❑.NO
<br />10a. MARITAL STATU9� AT 17ME OF DEATH � lr] Merried - 0 Never MeMed 10b. NAME OF SPOU3E (Flret,-Middle, Lest, 3uftlz) Ii wife, gtve maiden nema �
<br />li
<br />❑M�m�,�cee��, ❑,ma�a oo��, ❑u��a�, Janet Pronske
<br />11. FATHER'S-NAM6 (Flret, Mlddie, Leat, SufNc) 12. MOTHER'S-NAkiE (Firet, MMdle, Melaen Sumame)
<br />13. EVER IN U.S. AHMED FORCES7 Oive datas of service if yes. 14a INFORMANT NAME
<br />(Yes, no, or unk.) �
<br />16. METHOD OFOISPOSITION 18a. EMBALMER-81�NATURE � i8b. LICENSE N0.
<br />❑8��� ❑o�u� Not Embalmed
<br />� CremsUon ❑ Entomhmant . 78d• CEMETERY, CREMATORY OR O1NER LOCATION � CITY / TOWN
<br />ORamovei ❑o,na�cs�r„> Heafey Crematory, Omaha, N'�braska�
<br />17a FUNERAL HOME NAME AND MAILINO ADDRE35 (3lreet, Ciry orTovm, 8tate) � .
<br />Moser Memorial ChaAel. 2170 North Somers. Fremon
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wlf e
<br />18c. DATE (Mo., Day, Yr. J'�
<br />Jul� 19, 201C
<br />STATE
<br />. 17b. ZIP Code
<br />� 18. PART I. Enter the chain oT even�--dlaeases, Injudes, o� compllcatione-that directly caused ihe death. DO NOT etHer tertninel eveMS euch as ceMfac e��est, '' APPROXIMATE INTERVAL
<br />�
<br />respirarory errest, or venMcular Flbrilletton wkhout showing the etlology. p0 NOT ABBREVIATE. Enter only ona ceuse on a ifne. Add edtliHonai Iines if neceasary. �
<br />IMMEDIATE CAUSE � I oneet fi death
<br />m�nwr� rru,sE,� ce� ('� P.b'lC�.- ( Gl ���'vt t�'u� � / U1 r
<br />tlisea� or oomlidon resuitlng DUE T0, OR AS A CONSEOUENCE OF: � � onset to
<br />In death) � . . �
<br />SsqueMlally Ilat oondttlone,�. (b1 . . . . � .
<br />H arry, leading to the oaase DUE T0, OR AS' A CONSE�UENCE OF. � onset W death
<br />I
<br />�ISma on nire a � � � �
<br />EntarthaUNDERLYIN6 (�j . . . � � .
<br />� CAUSB (dlaease or Im�uy tl�at DUE TO, OR AS A CONSEQUENCE OF. � � � � onaet to death
<br />i�rc�red r� �me reamw�e
<br />In tleath) LA3T � .
<br />�� �
<br />I_
<br />18. PAflT il. OTHER SIQNIFICANT conMbutlng to tha tleath but rrot resuitlng in the underiying cauae given tn PART I: 78. VdAS MEDICAL EXAMINER
<br />� � OR CORONER CONTACTED7
<br />❑ YES �I NO
<br />20.IF FEMALE: ' � 21a. MANNER OF DEATH 276. IFTRANSPORTA770N INJURY 21a WA3 AN AUTOP3Y PERFORMED?.
<br />❑ Not pregnant wtthin past yeer , Naturai ❑ Homictde .❑ DrlvadOperetor � �
<br />� ❑ Peasenger 0 YES' �NO
<br />. 0 PregnaM at tlme of death ❑ Axfdent O Pending ImresUgaGon
<br />❑ Not pre'�neni, but pregnarit wiWn 42 days of death �' ❑ PedesVian p7d. WEIiE AUTOPSY FINDW�3 AVARABLE TO
<br />❑ smcide 0 Could not 6A determi�ed ��r (SpecHy)
<br />❑ Not pregnerlt, but prepnant 43 deys to 1 year betare death COMPLETE CAUSE OF DEATH?
<br />O Unlmown if pregnani within the pael year , ❑� YES 0 NO
<br />22a. DATE OF INJURY (MO., Day, Yr.) � 226. i1ME OF INJURY 22c. PIACE OF INJURY-At home, tarm, streeG �ry� ottica 6uiltl�ng, coretrucUOn site, etc. (SpeclyJ
<br />m . � � �. .. ... _ _._ -�.�-.____:_�"-- �--.- �--��_
<br />- -- - - . . _ . - -.- .__�__ - . ._ .�- , . . . _ - - - - -
<br />22d. INJURY AT WORK1 � 22e. DESCRIBE HOW INJURY OCCURRED� . � �
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY • STREET & NUMBEfl, APT. N0. CITYffOWN STATE 21P CODE
<br />23e. DATE OF DEATH (Mo., Day, YrJ � � 24a. DATE 31aNED (Ma, Day, Yr.) 24b. T7ME OF DEATH
<br />�� Jul 18 2010 .�� � "�
<br />� 23b. DATE SI�N D(Ma, De Yc � 23c TIME tlF DEA'�'H � ��� 24c. PRONOUNCED DEAD (Mo., Dey,Yr.) � 24d.TIME PRONOUNCED DEAD
<br />E '�Z July �19, 2�1b , � E�aZ m
<br />$ �� 23d. To the of my Imowledge, death occurted at tfie tlme, dete and plAca � 8��� 4e. On the basis of ezeminetlon andlor hrvastlgetion, In my opinton death occurred at
<br />�- '. � and d to h cause ) atated. Tttle )♦ ,$ o the Nme, tlate and place and due to the cause(s) etated. (SlgneNre and Title )♦
<br />�� ;� �$s
<br />�..
<br />26. DID TOBACC USE C NTRIBUTE TOTHE DEATH? � 28a HAS OROAN�OR TISSUE DONATION BEEN CONS�DERED2 28p. WAS CON3EM' GRANTED7
<br />O YES � NO � 0 PROBABLY ❑ UNKNON/N ❑ YES 0� Not A Iicable If 28e IB no ❑ YE3 NO
<br />- 27. NAME, TfR AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSIC�MI ASSIBTANT, C RONER'S PHYSICIAN OR COUNTY ATTORNE`Q �(fype or Pdnt) �
<br />28a. REQI3TRAA'S SIGNATURE
<br />�
<br />�28b. DATE FILED BY REOISTRAR (Mo., Day, YrJ -
<br />JUL 2 2 2010
<br />HHS-61 Rev.7/09 (55061)
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