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201�.03541 "��A�
<br />LINCOLN, NEBRASKA , j��/���
<br />A �.Y
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<br />- -_"._. __ ___-__ __ __. __-_ . *� + �i1 •
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC�S'
<br />. WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HIF�,4LTH AND HUMAN SERVICES, IT CERTIFIES
<br />` THE BElOW TO BE A TRUE COPY OF THE ORIGINAt RECORD ON FILE WITH THE NEBRASK,A"DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VI7'AL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITA1; J4�CO�tIaS. " .
<br />' DATE OF ISSUANCE �� t t;�
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<br />r�l�� ' Q e� ���� , STANCEYlS:4C'�OPER '�;
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<br />yle Byron Burke
<br />CITY AND STATE QR TERRITORY, OR FOREI6N COLNTRY OF BIRTH
<br />�Murdo, South Dakota
<br />, 7. 80CU1L SECURIIY NUMBER
<br />,!8b. FACILM-NNNE (tt �rot NsBdrtton. 9he etreet mM numher)
<br />i�202 East 13th
<br />ea crtr oR TowN oF oearH �wda eP coae)
<br />Wood River 68883
<br />8a. RESIDENCESTATE 9b. COUNTY
<br />�Nebraska Hall
<br />Isa. sraEEr anro Nume�
<br />202 East 13th
<br />I10a INARITAL STATUB AT TIIME OF DEATH � Martied ❑ Nevet INm
<br />❑ eea,.iea� tws �re�ea p wna�a ❑ owor�a ❑ u�o.,�
<br />STATE OF NEBRASKA
<br />�irc�'�"�'
<br />.F, .
<br />H. i
<br />0 �'.� �� ����,,:8.. �... -�
<br />March 10, 2011
<br />8. DATE OF BIRTH (Nlo., Day, Yr.)
<br />July 22, 1929
<br />H03P�7AL: � InpetlmR g=y�g; Q Nmsing Home(LTC ❑ Hospica Fadlity
<br />❑ ERlOatpetleM � Decedant'e Biome
<br />❑ oon ❑ ou,eqs�ec�jr)
<br />aa. counm oF oean+
<br />Hall
<br />9c. CITY OR TOWN
<br />Wood River
<br />9a APT. NO. 9� aP CODE 8g. WSIDE CR1F LIAAITS
<br />68853 � Y� ❑ �
<br />1Db. NA6sE OF SPOUSE (Flrst, lAldrDe, Leat, SWPoc) B tWie, glve malden neme.
<br />LaVonn Ropan
<br />i t�. FarHEas-nwme �t�se, mtaaia �sr, sur�c)
<br />Lafa ette Burke
<br />� 13. EVER W U.& AR6SED FOItCEB? Ghre datea of eeMce If Yee. 74a. INFORMANT•NAAAE
<br />r�.No,mu�.� Yes 01/08/1948-1?J27/1951 LaVonn Burke
<br />j 18. AAETHOD OF DtSPO8IT10N 1Ba EM -SIO
<br />�,'. �Buriai �DOrmtiun �� �j( ��
<br />r�wt v�• i
<br />❑cremetton ❑emmamm�am
<br />. � R ��� ❑����� 18d. CEM , CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />�Apfel Fu e al H me,�112�3�WG2nd,�Grand Island, braska
<br />2 sEX
<br />� Male
<br />8a. AGE-Last Birthday Bb. UNDER 1 YEAR Bc. UNDER 1 bJ1Y
<br />(Yra) MOB. DA1fS HOURB AAWB.
<br />81
<br />se. ru►ce oF oeani
<br />CAUSE OF
<br />�1&PART4ENertha �Sfnofevenis.�QSea�e,�n)�ulve,mmmP�mm-Umtdfredt�
<br />respiramry artea; or vanMalernbrWaUen without ehowt� tlre eNOlagy. Oo Nor /16
<br />IEAA�EDIATE CAUSE
<br />IM99EDU1TE CAUSE (Flnel � � 'l' ��
<br />c�sease or eomDtlon resulUng a) e� a
<br />ip death�
<br />� Dl1E TO, OR AS A CONSEQUENCE OF:
<br />�queMtally tls! Cortdidmre, B b)
<br />�ny, leading to the aauae Ileted
<br />��� a ' DUE TO, OR AS p CONSEOUENCE OF:
<br />EMer the UNDERLYING CAUBE �)
<br />(diseese or InJmyr thet Initlated
<br />the eveMa iesultlng in death) DUE TO, DR AS A CONSERUENCE OF;
<br />4A8T
<br />�a moniEas-w�eee �rvsr, �ame, ee�aen s�rneme�
<br />Mildred Brunson
<br />�en. ucq�se No.
<br />i3�d
<br />C1TY/1'OYIIN
<br />Grand Island
<br />e instructions and example:
<br />NOT eNermtnUnel eveMa such ea rardlee mreffi.
<br />mre ceusB On a Q�m. Add Bddflbt191 MBS B�y.
<br />14b. RELATIONSFI�+ TO DECEDENT
<br />Wde
<br />18a DATE (�o« �9. Yr.)
<br />March 15, 2011
<br />BTATE
<br />Nabraska
<br />68801
<br />APPROIONIATE WTERVAL
<br />o�reat to deafh
<br />� � tti!'� .T
<br />onset to death
<br />a�reat to death
<br />mmet to deeth
<br />d)
<br />��B. PART 0. OTHER BIGNIFICANT CONDITION9-Condidmis eo�l6utl� to the death but rro! resuiting�in the �mdeAying cause ghren In PART 4 19. WAS ElEDICAL E7(AAAINER
<br />OR WRONEIt CONTACTED9
<br />� /�r1T11� Cc�►�J� CHF �'1„f�. Je emb�6►� �fiabt� �-'l ��afbrm� ❑„� �'"�
<br />W ����• - 21 !d/tNNER OF DEATH b. ATiON �NJURY 21c. W/18 AN AUTOPBY PERFORAAED9
<br />LL
<br />� [] NM pregnaM wNhin paet year � Nahual ❑ Hamidde ❑ DrlvedOperator ❑ YES t� NO
<br />v p r�eanmrt � nme or a�rn ❑ a�ciaane ❑ Pemllug Imrestl9eNon ❑ Passe�er
<br />21d NfERB AUTOPSY FlNOWf�B AVAILABLE
<br />❑ Not Pre9�ea, hut Pregnant wifhln 42 deys oi death ❑ Sutclde ❑ CoWd not be datenNrred ❑ Ped�trian TO COlLPLETE CAUSE OF DEATHT
<br />� � Not PregnaM, 6u[ pregnmR 43 daya to 1 ye� betore death � ❑ Other (&Pe�1tY) ❑ YES ❑ NO
<br />� �]Unknown H pregnent wMhin dre past year
<br />m
<br />a _ --.__ _- --_ �--
<br />O ��¢2a DATE OF INJURY (EAa,.Oey. Yr.) 22b. TIdIE OF INJURY 22e. PLACE OF INJURY-At hema, tarm, street, Tectory. offiee bu�mng. eor�sWtructlon stte. e6e, (Bpeclfy)
<br />U m
<br />� ',�2d INJURY AT WORK? �e. D6CRIBE HOW WJURY OCCURRED
<br />�"' ❑ YES ❑ NO
<br />LOCATION OF INJURY - 9TREET & NUMBER, APT. NO. CITY/TOWN STd7E ZIP CODE
<br />23a. DATE OF DEATH (Mo., Dey, Yr.) 24a DATE SIONED �mo., Day, Yr.) 24b. TI�AE OF DEATH
<br />� . . .. __._ ._ __ ..
<br />F- Mal✓G� /0 Z0 fl _ .a�� m
<br />� F 23b. DATE StONED (MO, Dey, Yr.) 23c. TIME OF DEATH �� O 24c. PRONOUNCED DEAD (Mo, Day, Yt.) 24d. TIME PRONOUNCEU �EAD
<br />��z l� /i 'y-�Ja /� m E�a z m
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<br />23d. T the aP my knowledge, deafh occurted at the dme, date ar�d ptece � y� 24e. On the basia of e:mNnedon m�dlm ImesUgatiun, in my opinton deafh occurted
<br />o� mM due to fhe aeuae(a eteted. (81gna0ue ,� � 0 at the time. date mM P�ece am! due to tlre aeuse(e) stated. (Slgrteture mM Tide)
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<br />4& DIO TOBACCO USE CON7RBUTE TO THE DEATH7 28a HAS OROAN OR TIS9UE OONATION' BEEN CONSIDERED? 28b. WAS CONSENT 6RANTED4
<br />❑ YE8 ❑ NO ❑ PROBABLY ,�UNIWOWN ❑ Y83 °� NO Not App➢cabla B 28a Is NO ❑ YE8 ❑ NO
<br />27. NAME, TITLE ANO ADDRESS OF CERTIFlER (PHY81qAN, PHYSICUW ASSISTANT. CORONER'8 PHYSICUW OR COUNTY ATTORNEI� (Type or PrIM)
<br />Mark A11en Tompkins M.D. 3758 Frostfire Ave. Grand Island NE 68803
<br />zee. REr�sranas s�ow►rur� Q �. uare Fn.eo sr �c�srw►n �mo., oar. r..�
<br />P � � " MAR 2 � 2091
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