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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AM��ft�MMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA"D,�P�f��l�'MT(�F HEALTH AND
<br />HUMAN SERVICES, VITAl. RECORDS OFFICE, WHICH IS THE LEGAL DEPOSII"ORY FOR- Il�"f'�6L'l���ORDS "�
<br />� ��� . � pQ
<br />DATE OF ISSUANCE ,' ! t : . � ���"U-" "- . °�;
<br />07/14/2011
<br />LINCOLN, MEBRASKA
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN
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<br />1. DECEDENTS•NAME (First, Middle, Last, Suffbc) 2. SEX r„ �° 3. ,l'�'�F'OEAIH (Mo., Day, Yr.)
<br />Ruth MnSkeen Perkins Female July.lf1;�011
<br />4. CITY AND STATE OR TERRITORY, qR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(�'B•) MOS. DAYS HOURS MINS.
<br />Grand Island, Nebraska 66 July 10, 1945
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />505-52-6923 HOSPITAL � InpaUent OTHER ❑ Nuraing Home/LTC � Hosplce Fac11Hy
<br />8b. FACILI7Y•NAME (If not InsUtutlon, give street and number) � ER/OutpaUerR � DecedeM's Home
<br />�
<br />° 3020 Colonial Lane ❑ DOA ❑ otner �sReciry
<br />U
<br />� 8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF UEATH
<br />c Grand Island 68803 Hall
<br />� 9a. RESIDENCE-STATE 8b. COUNTY 8c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL 8d: $TREET AND NUMBER 88. APT. N0. 8f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />�, 3020 Colonial Lane 68803 � vES ❑ No
<br />.$ 70a. MARITAL STATUS AT TIME QF DEATH � Marrled � Never Manted 10b. MAME OF SPOUSE (Flrat, Mirldlo, Last, Sufflx� If wNe, glvo malden namo
<br />€ ❑ Marrled, but separated ❑ vinaowed ❑ Divorced ❑ Unknown Charles Lloyd Perkins
<br />m
<br />� 11. FATHER'S (First, Middte, Last, Sufflx) 12. MOTHER'S•NAME (First, Middte, Maiden Sumame)
<br />� Joseph Love Martin Alv(ra Annabe0e Comelius
<br />°' 13.,EYER IN U.S. ARMED FORCES7 Give dates of sarvice iFYes. 14a. INFORMANT•NAME 14b. RELA170NSHIP TO DECEDENT
<br />E
<br />s (Yea, No, or un►c.) No Charles Lloyd Perkins Husband
<br />� 15. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., bay, Yr.)
<br />F °., � Burlal ❑ Do�tlon
<br />Matthew T. Myers 1411 July 14, 2011
<br />❑ Crematlon Q Errtombmerd 16d. CEMETERY, CREMQTORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Speclfy)
<br />WesUawn Memorlal Park Cemetery Grand Island Nebraska
<br />77a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, Stata) 17b. Zlp Code
<br />Ali Faiths Funerai Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEA H See instructions and exam les
<br />18. PART 1. Enter the chain ot events-�diseases, InJurlea, or complicatlonsdhat dlrectiy pused the tleath. DO NOT errter terMnai events such as cardlao arteaY, = AppROXIMATE INTERVAL
<br />reepiratory artest, or verrtricular flbrillatlon without ahowin8 �e e8ology. DO NOT ABBREVIATE Frrtaz oniy one cauae on a Ihre. Add atldttlona116res H rteceaeary.
<br />IMMEDWTE CAUSE: ; onset to death
<br />IMMEDIATE CAU3E (Finat a1 Respiratory Failure ;< 1 Week
<br />disease ar conditlon rasulUng
<br />In aea�h) pUE TO, OR AS A CONSEQUENCE OF: ; or�set to death
<br />sav��nr��s��awo,�.�r b)Malignant Glioblastoma Multlforme � 1 Year
<br />any, leading to fhe cause Ilsted
<br />on Ilne a.
<br />DUE TO, OR AS A CONSEQUENCE OF: ; oreet to death
<br />Enmrsne uNOew.riNO cnusE �)
<br />(disease or InJury that Inidatetl
<br />ths eveme resuiting In death) DUE TO� OR AS A CONSEQUENCE OF: 0 ortset to death
<br />�.asT d)
<br />18. PART 11. OTHER SIGNIFlCANT CONDITIONS-Conditlons contributing to the death but not reaulUnp In the underfying cause givan In PART I. 18. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />W 0. IF FEMALE: 27a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />� �� Not PreBnant wMhin past year � Natural � HomiWde � DHvadOperaWr ��S � NO
<br />v p are � n� a a�m �] a�uaam � Pendin8lmesd9atlon ❑�"e�
<br />T � wot pregnant, but pregnant wnnin 42 days of death � PedesMan 27 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />.p � Suidde � Could nM be daterminetl ❑ TO COMPLETE CAUSE OF DEATHI
<br />, � Not pregnam, but pregnaM 43 tlays to 1 year betora tleatl� p�� (gpe�Mr)
<br />� ❑ Unknown H Preenairt w�thin the past year ❑ 1�E3 Q- Gl0
<br />� 22a. DATE pF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY At home, farm, atreet, factary, offlce buliding, construcUon sfte, etc. (Speelty)
<br />�
<br />.� 22dJNJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />f' ❑ YES ❑ NO
<br />22t. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. T7ME OF DEATH
<br />.� � July 10, 2011 � � �
<br />��� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ��� y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />E � Z Jul 12, 2011 07:28 PM �` a< Z
<br />$ � 3d. 7o the beat of my Imowledga, death occurred at tha Ume, date antl plaee $ � 24e. On the baels oi e�mmination and/or invesdgatlon, In my opiNon death occurtad at
<br />�� a�M due M the cause(s) s�ted (Signature and Titte) �� tha tlme, date and place and due to the cauae(s) sY�ted. �Signature antl Tkle)
<br />~� JenN fer L. Brown, M D '' � s
<br />2S. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED7 28b. WAS CONSENT GRANTEDI
<br />� YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applicable H 26a Is NO � YES ❑ NO
<br />7. E, TITLE n ADDRESS OF CEItTiFiER (P SIC , SI IAN ASSIS AN , COR NE S PHYSICIAN OR COUNTY A ORNEI� (Type or Prirrt)
<br />Jennifer L. Brown, MD, 729 North Custer Avenue, Grand lsland, Nebraska, 68803
<br />28a. REGISTRAR'S SIONATURE �_ 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />July 13, 2011
<br />Exhibit "A"
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