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<br />� '�-� STATE OF NEBRASKA
<br />` W�iEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH A/V'D MUMAIIF �ERIII'CES,t IT CERTIFIES
<br />' THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPA���'�j,� M�}L(',TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL�E`CO �;�;� �,,
<br />DATE OF ISSUANCE � � � � �
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<br />� STANt�'�r� CO,OPER �'' �. - y'; ��+
<br />A ���9ZO11 �0�, t10G24� DEP ,�
<br />tINCOLN NEBRASKA ' HUMsQN��jZV1 : =`" �'
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<br />STATE OF NEBRASKA - DEPARTMENT OF NEALTH AND HUMAN SERVICE�4 ,�``� J �., � ' `
<br />� CE TIFIC TE OF DEA H �}`' �' ���'•�" �-��'
<br />1. DECEDENT'&NAME (Flrat, INiddle, Last, SWflx) 2 SEl( �.. � �A �� . ,�D$ATtf � .9ay,Yt,�.�.� .
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<br />Nadine Claire Ruple
<br />0. CITY AND STATE OR TERWTORY, OR FOREI6N GOUMRY DF BIRTH
<br />Lincoln, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />. 8b. FACILITY-IdAME (B not Instltuticn, gfve straet erM mrmber)
<br />Good Samaritan Society-Grand Island vllage
<br />8c. CITY OR TOWN OF DEATH Q�Iude ap Code)
<br />Grand Island 68803
<br />9a RESIDENCE-STATE 96. COUNTY
<br />Nebraska Halt
<br />9d. STREET AND NUdIBER
<br />2410 N. Sheridan Ave
<br />10a MARITAL STATU9 AT TIME OF DEATH � Mertied ❑ Ne+rer Ma�
<br />❑ me�ea. ew ��saa ❑ wna�a ❑ onro.�a ❑ un��,
<br />11. FATHER'&NAME (Flrst, Mlddle, Lasf, Sutflxj
<br />Female May4;'�0�`�-"=- '
<br />Ba A6E-Leat Birthday Bb. UNDER 1 YEAR Be. UNDER 1 DAY & DATE�OF BIRTH (Mo., Dey, Yr.)
<br />(Yra) 6705. DAYS HOURS MINS.
<br />77 - August 15, 1933
<br />�� 8a. PLACE OF DFATH
<br />HOSPRAL: � Inpatlerrt � OTHER; � Nu�sing Home/LTC � Haepica Facitky
<br />� ❑ ER/outpa9eM ❑ neeeae�rB Hor�re
<br />�re
<br />� DOA � Other(Speciry)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. C1TY OR TOWN
<br />Grand Island '
<br />8a. APT. NO. Bf. ZIP CODH 9g. WSIOE CITY UMITS
<br />• 68803 � Yee ❑ No
<br />tOb. NAME OF SPOUSE (6�rak M�ddle, Last, 3uHix) NwRe, give melden name. ,
<br />Raoul Roaer Ruole
<br />72 AEOTHER'8-NA69E �(Flrst, MWdle, AEaiden Sumeme)
<br />13. EVER IN U.& ARMED FORCES? Gire detes of aervica if Yea. 14a WFOReAfWT-NAAAE
<br />�1les, No, w unk� Np 17Stlne J ft
<br />18. AAE7HOD OF GISPOSITION 18a EM dIE IG ATURE
<br />�e� poo��o� `'
<br />�crenmeon Qenmmmmm �
<br />�Remo�e� QothaMe�y� 1Bd CEMETERY, CREMATOR OR THER LOCA710N
<br />Grand Island City Cemetery
<br />17a FUNERAL HOME NAME AND MAILINO ADDRESS (Street, Cky or Town, $fete)
<br />All Faiths Funeral Home, 2929 S. LocUSt Street, Grand Island, Nebraska
<br />taePl�etoq' a?est.
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<br />UtlIdIED1ATE CAUSE {Flnal
<br />disease or ComllNOn tesulU� a) ;
<br />in death)
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<br />DUE�O, OR /LS A CONSEQUENCE OF�
<br />Sequentlelly Iiat wnditlorre, If � /a���� l �
<br />mry. lea�ng to tt�e cauae Iisted b) c' � .��� �
<br />°O �� a DUE TO, OR A9 A CONSEQUENCE OF:
<br />Emer the UNDERLYINa CAUSE �)
<br />(disease or inJury that InWeted
<br />the eveMs resutdng In death) DUE T0, OR AS A CONSEQUENCE OF:
<br />LAST
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<br />1& PART IL OTHER SIGNIFlCANT CONOITIONS-Condido�re contributing to the death but not resuitlng In the undedying cause given in PART 1.
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<br />q:. ot pregnaM wkhin pae! year
<br />W ❑ Pregnant at tlme oi death
<br />V ❑ Not pregnent, but pregnant wlthln 42 deya M death
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<br />.O ❑ Nat prepnant, but pregnaM 43 daya to 1 year before
<br />� �Unknorm � P�e9nan� within the past year
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<br />27 NER OF DEATH 21b. tF TKANSPORTATION
<br />Naturel ❑ HoMdde ❑ DrivedOperator
<br />❑ Accldent ❑ Pendhtg Investlgatlon ❑ Passenger
<br />❑ Su�cide ❑ Cautd rrot be determtrred ❑ Pedestrian
<br />❑ Other (SP�HY)
<br />14b. RELATIONSHIP TO DECEDENT
<br />16c. DATE (Ma, Day, Yr.)
<br />May 9, 2011
<br />STATE
<br />Nebraska
<br />68801
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<br />� Of188t�0lI88�V1
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<br />� onset M daafh
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<br />� onsat W death
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<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CO ACTE�9
<br />❑ YE3 NO
<br />21a WAS AN AUTOPSY P ORMmT
<br />❑ YES O
<br />21d. WEREAUTOPSY FlNDIN6S AVAILABLE
<br />TO COMPLETE CAUSE OF DEATHT
<br />❑ YES ❑ NO
<br />0 22a DATE OF INJURY (Mo., Day, Yr.) 22b. TIAAE OF MJURY 22a PLACE OF INJURY-At home, famy eVeet, factory, offlce buildfng, construcfion atte, eta (Spacify)
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<br />0 � ZZd. INJURYAT WORK7 22e. DESCRIBE HOW INJURY OCCURRED
<br />E" ❑ YES ❑ NO
<br />22f.. LOCATION OF INJURY - STREET & NUd19ER, APT. NO. CITY/TOWN BTATE 7JP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) �� 24a DATE SIGNED (6Co., Oag, Yr.) Z4h. TIA9E OF DEATH
<br />a"-� Ma 4 2011 aU Z� �►
<br />LL 23b. UATE SIONE� (Mo., �ay, YrJ 23c. TIME OF DEATH � O 24a PRONOUNCEO DFAD (Mo., Dey, Yc) 24d. TIME PRONOUNCEO DEAD
<br />� K� ). � � � F- Y ,
<br />�aZ M , 2011 06 a. E ya Z m
<br />$�� Z3d. o of my knowl ge, de occurted et the tlme, date and pleee $ W��� 24e. On the baels of e�caminatlon andlor Imeadgadon, In my oplNen death occurted
<br />a� na e e cause(e� ienae�e nnd naa� $� o es ctre nme, dace a�w aace e„d aua � u,e ca„��a� s�a►�. �signaaue emi nna)
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<br />. 26. DID TOB E CONTRIBUTE TO E EATH9 28a. HAS ORGAN OR TISSUE TION BEEN CONfi1DERED? 26b. WAS CONSENT GRANTED?
<br />❑ YES NO ❑ PROBABLY UNKNOWN ❑ YES NO � Not Appltcebte fl 28a la NO ❑ YES �10
<br />' 27. NAASIE, T171E ANO ADDRESS OF CERTflER (PHYSICIAN, PHYS�CWN ASSISTANT, CORONER'S PHYSICUW OR� COUNTY A7TORNE� (Type or PNM)
<br />John A. Wagoner, M.D. 800 Alpha, Gr nd Island, Nebraska 68803
<br />26e. REGISTRAR'9 SI�NANRE � 28b. DATE FlLED BY REGISTRAR (Mo, Day, Yr.)
<br />P �• Mar Y o 2o�t
<br />CAUSE OF DEATH
<br />m eomPncaUOna-thet diractiy cauaetl the Ee
<br />whig the etlology. DO NM ABBREIMTE Etr
<br />78b. LICENBE N0.
<br />CITYITOWN
<br />Grand Island
<br />e instructions and example:
<br />NOT eMe�m�minel eve�rta euoli ea eermac arteet,
<br />one muae on e Me. Adtl aOAitlonai n�res rc,receaeery.
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