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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEf#
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FI�E WITH THE NE�lL9,
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY F0,/��"V'
<br />� .,
<br />DATEOFISSUANCE �, i �,�
<br />' 03/18/2010 � Q �, �, � �i � � �, � "��- �
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<br />��� LINCOLN� NEBRASKA ;' � aH
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S�I
<br />if'A�D.tiUMAN SERVICES,IT CERTIFIES
<br />'l� 6� -F, ,P�613'7``M�1VT OF HEALTH AIVD
<br />A�L> �2�C,�(9�S c' �,,
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<br />! 5. COOPER y ''..', ` A� . . `
<br />N �ERI/3�E�, " ;� ;' ,`�, :
<br />'�l�'t�° Ptt �'�� � ';''+ 10 00722
<br />GtKI1rIGAlt Vt UtAIF1 �w�,r -• ��..
<br />1.',bECEDENT3-NAME (First, Mlddle. Last, SuHbc) 2. §�C,,, ` .� 'd ,i .a.'�ATE OP DEATH �Mo., Day, Yr.)
<br />°Geraldine Mauine Kennedy Femal'e .,� �� ��"iVlarch 5, 2010
<br />4.'�ITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last BiRhday b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yre•) MOS. DAYS HOURS IWNS.
<br />Alliance, Nebraska 87 October 8, 1922
<br />7. OCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />507 osPR � InpaUent OTHER ❑ Nursing Home/LTC � Hospica Facillly
<br />Sb'. FACILITY•NAME (H not Ir�stltutlon, give street and numbaz) �
<br />� ❑ Outpatierrt ❑ Decederrt's Home
<br />� Saint Francis Medical Center ❑ Doa ❑ oc��r�spae�-°
<br />�
<br />BaG C11Y OR TOWN OF DEATH (Include Zip Code) Bd. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 9a, RESIDENCE3TATE 8b. COUNTY 8c. CITY OR TOWN
<br />Z ',Nebraska Hall Grand Island
<br />LL 8d. STREET AND NUMBER 8e. APT. NO. 8f. ZIP CODE 9g. INSIDE CITY UMITS
<br />a 637 N. Howard Ave. 68803 � vES ❑ No
<br />'� 70 . MARITAL STATUS AT TIME OF DEATH Q Marcled ❑ Never Manied 10b. NAME OF SPOUSE (Ftrst, Middle, Last, Suffix) If wNe, give malden name
<br />�
<br />d
<br />� ❑ nnamaa, bu� separated � Wldowed ❑ o�or�aa ❑ Unknown qmold Joseph Kennady
<br />� 1'�" FATHER'S-NAME (First, Mlddle, Last, Suffi�c) 12. MOTHER'S•NAIV� (First, Middle, Maiden Surname)
<br />� Frank Dillon Anastatia McNurtny
<br />°' 13' EVER IN U.S. ARMED FORCESI GWe dates of servica H Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP YO DECEDENT
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<br />$ �r�, No, or unk.) No Joseph Kennedy Son
<br />,� 19F METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 16b. LICENSE NO. 18c. DATE (Mo., Oay, Yr.)
<br />F � BuMai ❑ Donatlon
<br />Ronald J. Levander 0941 March 9, 2010
<br />� CremaUon [] Entombment 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Removal ❑ Other (SPeeBy)
<br />St. Anthony's Catholic Cemetery Cedar Rapids Nebraska
<br />1Ap. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, S�te) 17b. Zip Code
<br />�Levander Funeral Home, 308 W. Marenga St., Albion, Nebraska 68620
<br />CAUSE OF D TH See Instructlons and exam es
<br />1&� PART 1. EMer the chaln of eveirts-�diseasea, InJuriea, or complicallona•that dlraWy caused the death. DO NOT eMe� tarminal eveMS euch as eardiac arteat, ; APPROXIMATE INTERVAL
<br />respiratory artest, or ve�rtrlcuiaz flbrlllation wkhout ahowing the etiology. DO NOT ABBREVIATE EMer oNy one cause on a Ii�re. Add eddklonal 0�res H imceseary.
<br />IMMEDIATE CAUSE: ; o�et to death
<br />IMMEDIATE CAl1SE (Flnal 0) Subarachnoid Hemorrhage E<1 Week
<br />diaease or condWan resultlng
<br />� d � ' � DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />S¢quentlally Ilst condidona, �r b) Hypertensfon ; Years
<br />arry, leatline to Ne causa Ilated
<br />on Ii� a '
<br />DUE T0, OR AS A CONSEQUENCE OF: � onset to death
<br />Ejrterthe UNDERLYIN6 CAUS� C �
<br />(disease or iryury that Initlatetl �
<br />e aveMa reaWbng In death� OUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />� d)
<br />0
<br />18� PART II.OTHER SIGNIFICANT CONDITIONS�ondiUons coMributing to the death but not resulUng In the underlyi� wuse gben in PART i. 18. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />a , [] YES � NO
<br />W 20i IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />LL
<br />� a Not pwgnaM wlthM past yeaz � Natural � Homldde � DrIveAOperator
<br />W PregnaM at tlme of death � Paseenger ❑�S � NO
<br />V � � AceideM � Pending Investi8aflon
<br />� � Not pree�M. but pregnarrt within 42 days ot death Suidde Could rrot be determtnetl � P���" Z� d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />�] Not pregneM, but pree� 43 deYe to 1 year before death � � � Other (Spacity� TO COMPLEfE CAUSE OF DEATH?
<br />� � UnknownlfPreBnantwithlnNreP�Year ❑ YES ❑ NO
<br />°' 22a. pATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, tartn, street, factory, office building, eonsWetlon sfte, etc. (Specffy)
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<br />c�
<br />.� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />� , p v�s ❑ rvo
<br />. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />.� � March 5, 2010 3� � �
<br />�� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DE4TH �� k Y 24c. PRONOUNCED DEAD (Mo., Day, YrJ 24d. TIME PRONOUNCED DEAD
<br />E�i� Z March 15, 2010 03:45 PM � a<�
<br />$' 0 9d. To the beat of my qtow�ed8e, death occurrad at fhe dme. date end place $���
<br />��i� and due to Ure muea�e) ateted. SI nature and TiGe 8�+ � 24e. On the basie of eYaminffilon and/or inrestigadon, in my opinion death occurred at
<br />F ,� 1 e ) F& � me nme. aam ana P�ace ena aue w me cause�s� smcea. ts�e�re ana rme�
<br />'� Jennifer L. Brown, MD g o
<br />2 � DID T08ACC0 USE CONTRIBUTE TO THE DFATH7 ZBa. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREDT 26b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applicable Ii 26a Is NO ❑ YES ❑ NO
<br />2,l E, TIT E D DR O ERTIF ER (P SI , YSICIAN IST T, R NER O C A O rfype or Prlrrt
<br />Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />2. REGISTRAR'S SIGNATURE � w 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 17, 2010
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