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STATE OF NEBRASiCA
<br />WHEN THIS COPY CARRIES THE RAISFD SEAL OF THE NEBRASKA DEPARTMENT OF
<br />THE BELOW TO 8E A TRUE COPY OF THE ORIGINAL RECORD OAI FILE WITH THE N�
<br />HUMAN SER'VICE'S, VITAL RE�ORDS OFFICE, WHICH IS THE LEGAL DEPOSITORYfC
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<br />DATE OF ISSUANCE �°' � "
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<br />03/17/2011 2 0110 3 6 2 2 ,;�d , c�
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<br />LIIVCOLN, NEBRASKA #,�'' �
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAI� �SEI
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<br />SFRVIGES, 1T CERTIFIES
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<br />1. DECEDENT&NAME (Flrat, Mlddle, Last, Suffbc) 2. 3 ��.� , i �' DA7�'OF DEATH (MO., Day, Yr.)
<br />Gerre Marion Reab Male �larch 12, 2011 `
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. A(iE - Last Birthday b. UNDER 1 YEAR ' Sc. UNDER 1 DAY B. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y►$•) MO3. DAYS HOURS MINS.
<br />Giltner, Nebraska 83 July 28, 1927
<br />7. SOCI SECURIT NU MBER 8a. PLACE OF DEATH
<br />OH SPRAI. � InpaBerrt OTHER � Nuraing Home/LTC � Hospice Facility
<br />8b: FACILITY-NAME (Ii rrot I�titutlon, give street ami number) � ER/OutpaUe�rt ❑ DecedeM's Home
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<br />� �akeview-A Golden Living Center ❑ ooa ❑ otner �s�ciry>
<br />� 8c. CIIY OR TOWN OF DEATH (Irtelude Zip Code) 8d. COUNTY OF DEATH
<br />c Grand Island 68801 Hall
<br />� 8a',RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL 8d; STREET AND NUMBER 9e. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY LIMITS
<br />� 2617 Lakewood Drive 68801 � res ❑ No
<br />.� 10a. MARITAL STATUS AT TIME OF DEATH � Marcied ❑ Never Marrted 10b. NAME OF SPOUSE (Firat, Middle, Last, Suff6c) N wife, B�e rr�iden mame
<br />� ❑ nnarr�ed but separated ❑ uviaowed ❑ oworcea ❑ unicnown Ellinor Henriksen
<br />� � 71: FATHER'S-NAME (Flrst, Middie, Last, Suffbc) 12. MOTHER'S-NAME (Firat, Middle, Malden Sumame)
<br />Merle Reab Elizabeth Rupp
<br />°' 13: EVER IN U.S. ARMED FORCES? Gtve dat� oT servlca ff Y�. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />$ (Yea, No, or Unk.) Yes 07/12/1945-08/19/1946 Ellinof ReBb Wife
<br />,$ 18. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 16b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />� � sunai ❑ Donatlon Chris McCoy 1191 March 15, 2011
<br />� Cremedon Q Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />�j Remorai p ocner �spec�ry� Grand Island City Cemetery Grand Island Nebraska
<br />17�. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State) 17b. Zip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See Instructlons and exam les
<br />18. pART 1. EMer the ahain oi eveirte-diseaeea, InJuriea, or compllcadon�tha! dlrectly caueatl the death. DO NOT e�rter terminal ava�ria euch ¢s cardlac arrest, �; ApPROXINU►TE INTERVAL
<br />� respUatary ertest, or ve�rtriwlar flbrlilatlon without showing the etlWogy. DO NOT ABBREVIATE EMar onty are cauae on a Ihre. Add addklonal lhrea If necessery.
<br />° IMMEDIATE CAUSE: ; onset to death
<br />IMMm1ATE CAU8E (Fl�181 a) Respiratory Failure ; Days
<br />diaease or eorMitlon resuitlng
<br />In tleath� DUE TO, OR A9 A CONSEQUENCE OF: ; o�et to death
<br />Se'quentlally Ilst condiqone, Ii b) Pneumonia E Days
<br />a�ry. leading to the cause Ilatetl
<br />on,u�re a DUE TO, OR AS A CON9EQUENCE OF: ; oreet to death
<br />Fatterthe UNDERLYINO CAUSE C �
<br />(dlaease w InJury that InlUatetl
<br />me everrte reeuren¢ m a•au�) DUE TO, OR AS A CONSEQUENCE OF: i orreet to death
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<br />78: PART Ii. OTHER SIONIFlCANT CONDITIONS�Condltions conMbutlng to the death but rrot resulUng In the urrcieriying cauae given In PART I. 98. WA9 MEDICAL EXAMINER
<br />C�Oronary Artery Disease, Diabetes Meilitus, Hypertension, Hypedipidemia, Acute Renal Failure, Chronic Systolic Congestive Heart OR CoRONER CONTACTED9
<br />� Failure ❑ YES � No
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21C. WAS AN AUTOPSY PERFORMED?
<br />� � Not preBnaM wtthin P� Y� ��w� � Ho�aae p nrnreno��ro�
<br />� � Pregnantattlmeotdeadt � qccldeM � Pendin8lmeatigsdon ❑ P8��98� � � � NO
<br />� Q Na p�egna�rt, but pregnant wMhin 42 daye oT death � PedeaMan 21 d. WERE AUTOPSY FlNDINGS AYAILABLE
<br />� Suidtla � Couid not be determiired TO COMPLETE CAUSE OF DEATH?
<br />� Not PreB�errt. but PreBnent 49 days M 1 year betore death � Other (SP��M)
<br />� � Unlmown If preg�M wfthin the paet year ❑ YES ❑ NO
<br />� 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, fa►m, straet, tactory, offlce bulldl�, corretructlon aite, etc. (Spec(fy)
<br />$
<br />� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />❑ ves ❑ No
<br />22f. LOCATION OF INJURY • STREET $ NUMBER, APT.NO. CITYfTOWN STATE LP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.� 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />S March 12, 2011 ,� � �
<br />�� r 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH � k r 24c. PRONOUNCED DEAD (MO., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� Z MarCh 16, 2011 06:45 AM � a<�
<br />-�� 9d. To Ure best of my knowledge, death oecurted et the tlme, date and piace $� 24e. On the heals oT examinatlon and/or Inveatlgadon, In my oplNon death oearrted at
<br />a � d due m t h e c a u�(s) e m m d. ( S ig n a t u t e an d T k l e) �� the dme, date antl place and due to the cauee(e) staletl. (318nature antl Titte)
<br />~ � Jay C. Anderson, MD ~ � � .
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH7 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED7 26b. WAS CONSENT GRANTEDT
<br />� YES ❑ NO ❑ PROBABLY ❑ UNtOVOWN ❑ YES � NO Not Appllcable H 26a Is NO ❑ YES ❑ NO
<br />27. E, TITL D AD RESS OF R IFIER (PHYSIC , HYSIC ISTANT, COR ER S P OR CO N ype or hnt)
<br />Jay C. Mderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE �� 28b. DATE FlLED BY REGISTRAR (Mo, Day, Yr.)
<br />March 17, 2011
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