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� STATE OF NEBRASKA
<br />,
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH.Q ,ND,
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WTTH THE NEBR,95K1� U,EP�
<br />HUMAN SERVICES, VITAL RFCORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR�V,��L
<br />� � �L . �A Y �.
<br />DATE OF ISSUANCE
<br />04/15/2011
<br />Newark, New Jersey
<br />. SOCIAL SECURIT Y NUMBER
<br />150-40-5899
<br />����`ai��+,r �
<br />LINCOLN, IVEBRASKA � $����'�
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEtf�ll� �� � 5 k �`
<br />CERTIFICATE OF DEATH ' F , P ,, �� '. ". , , , � � ;�
<br />., DECEDENTS-NAME (First, Middle, Last, Suft6c) 2. SD( �' � � f+: 3,
<br />' Ellzabeth BettyLou Lomasney Femalb' �. �
<br />q CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 7 DAY 8,
<br />��d MOS. DAYS HOURS MINS.
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<br />4TE O�UEATH (Mo., Day, Yr.)
<br />priF7, 2011
<br />ATE OF BIRTH (Mo., Day, Yr.)
<br />I I I May 27, 1947
<br />O_ THER � Nursing Home/LTC � Hosplce Facllity
<br />�. FAGILRY•NAME (IT rrot InaUtutlon, g(ve atreet and number) � ER/putpetleM ❑ pecBdenYs Home
<br />Wedgewood Care Center ❑ DOA ❑ Other(Speeify
<br />, CITY OR TOWN OF DEATH pnelude Zip Cade) Bd. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />. RESIDENCE�STATE 9b. COUNTY Bc. CITY OR TOWN
<br />Nebraska Halt Grand Island
<br />!. STREET AND NUMBER 8e. APT. NO. 8f. ZIP CODE 8g. INSIDE CffY LIMRS
<br />1019 N.Hancock 68803 � v�s ❑ No
<br />a. MARITAL STATUS AT TIME OF DEATH � MarHed ❑ Never Married 10b. NAME OF SPOUSE (Firat, Middle, Last, Suffix) If w1fe, give malden r�me
<br />❑ mamea, nuc separared ❑ wndowed ❑ on�orced ❑ unicnown George Bemard Lomasney
<br />. FATHER'S-NAME (Flrat, Mlddle, Last, SuRlx) 12. MOTHER'S-NAME (Flrst, Middle, Malden Sumame)
<br />Walter Becker Helen Tabom
<br />. EVER IN U.3. ARMED FORCE34 Gfve dat� of seMce H Yes. 14a. INFORMANT-NAME 146. RELATIONSMP TO DECEDENT
<br />�Yes, No, or unk.) No George Bemard Lomasney Husband
<br />. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 18e. DATE (Mo., Day, Yr.)
<br />� aurtat ❑ oo�aon Daniel D Naranjo
<br />❑ Cremation � EMOmbment 1071 April 12, 2011
<br />❑ Removal iBd. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Othe►(SPecBY)
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />a. FUNERAL HOME NAME AND MAILING ADDRE33 (Street, City or Town, State) 17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />I& PART I. E�rtwthe chaln af eveMS��tll�asea, IryuAes, or compticatlons�Umt dlrecUy cauaed the tleath. DO NOT errter tertNnal events auch ea cartllao artest,
<br />�� reepiratory arreat, or ve�rtricular flbritlatlon wkhart ehowing tlre etiotog�r. DO NOT ABBREVIATE. EMer ony orre cauae on a 16re. Add addidonal tlnea I} ne�ry.
<br />IMMEDIATE CAUSE:
<br />i�m�oare cause (Fl� a) Respiratory Faflure
<br />diseaea or condttlon rasuidrtg
<br />�� �� DUE TO, OR AS A CONSEQUENCE OF:
<br />eav��ur i�c �o�awo�re, u b) End Stage Renal Dlsease
<br />airy, leatling to the cauae Ilated
<br />on Ihre a _- _. ..
<br />EMerthe UNDERLYINO CAUSE �) �ngestive Heart Failure
<br />(dlsease or InJury that InWatad
<br />��"� re �'�"g �" �'� DUE TO, OR AS A CONSEQUENCE OF:
<br />� d)
<br />�. PART U. OTHER 31GNIFlCANT CONDITIO�
<br />Cervlcal Cancer, Iron Deficiency Anemia
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<br />1. IF FEMALE:
<br />� NM pregnairt wkhln past year
<br />� are�nanca�w�emaeasn
<br />Q NM pregnaM, but pregrmM wfthln 42 days oi deffih
<br />� Not P�B�en1, but P�eB�a�t 49 daye to 1 y9ar betore death
<br />Q Unlmown N prepna�R wlfhln tlre past year
<br />!a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF
<br />INJURY AT WORK? I22e. DESCRIBE HOW INJURY
<br />❑ YES ❑ NO
<br />LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />23a. DATE OF DEATH (Mo., pay, Yr.) � 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />& � Ap�il 7, 2011 � �
<br />� � 236. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ��� 24c, pRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� Z A ril 12, 2011 05:15 PM '� d<�
<br />8� $' � 9d. To the best M my knowtedge, tleath ocwrted at ttm tlme. date and ptece $ �� 24e. On ffie basls of exambmflon and/or Imestl8�on. ln rtry opinlon death accumed ffi
<br />eiw aue u tlre eause(s) amtea. (Slgnaa,re ana rtne) 8�� a
<br />F F& $ the tlr�re. date and ptace and due to the cauae(s) efeted. (Slgnature and Tltle)
<br />Jennifer L. Brown, MD � ,
<br />�J YES � NO ❑ PR ❑ UNKNOWN � � YES � NO I Not Appllcabla H 28a Is NO � YES ❑ NO
<br />Jennifer L. Brown,�MD, 729 North CusterAvenue, Grand Islan Nebraska,i68803c Rc uNn #'irow��RyPeor r�m�
<br />APPROXIMATE INTERVAL
<br />onsetto death
<br />24 Hours
<br />onset to death
<br />> 1 Year
<br />ar�et to death
<br />> 1 Year
<br />oreet to death
<br />to the death but not resulU� In the underlying cauae gtven In PART I. 19. WAS MEDICAL D(AIWNER
<br />� NaWral � Homlcltle
<br />� Aecldent � Pentling Investlgadon
<br />� Sulclde � Coultl not be determUred
<br />22c. PLACE OF INJURY•At home,
<br />OR CORONER CONTACTED?
<br />❑ YES � NO
<br />Ib. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />� orrienoPe�a�or � �5 � NO
<br />❑ PBSSe�er
<br />� Ped�trtan 21d. WERE AUTOPSY FlNDINGS AVAILA
<br />�� � TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />farm. street, factory, offlee bullding, cor�truetlon slte, ete. (Speclfy)
<br />26b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />April 14, 2011
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