|
�, 110 6 3 3 G gTATE OF NEBRA3KA- DEpARTMENT OF HEALTH AND HUMAN SERVICE3 � iq �5►�y�
<br />CE TI ICATE OF DEATH `¢ �
<br />�. oeceo�rs-rur� (�rs�, e�uaat�, �4 e�) z sEx �. oare oF oenn+ In�+o.,oer
<br />Dorothy Margret Sumnick Female December 10, 2010
<br />4. CITY AND BTATE OR T6tRITORY, OR FOREftiN COUNTRY OF BIRTFi 9e. A6E-Last BMhday 56. UNDER 1 YEAR 8c. UNDER 1 DAY & OATE OF BUiTH (AAa., Oay, Yr.)
<br />�(Yre.) MOS. DAY9 HpUR9 MIN9.
<br />Catro, Nebraska 97 January 25, 1913
<br />7. SOCIAL 9ECURITY NUMBER �� Ba PLACB OF DEATH
<br />� 506-70-5165 t14� [] �m�B�u ���R:� Nura��8 HomelLTC � Hosplee Fecflilg
<br />V 8b. FACILITY•NAME (I( not Irotltution. 9Wa slrea! ertd m�mber) [� ER/Ou�PeflOM ❑ Dee�anPe Homa
<br />� The Lighthouse � p oon ❑ou�s�exy)
<br />0
<br />� eo. cm on rowri oF oFaa�n� p�a0 z� coae> sa. courrcv oF oenn�
<br />Omaha 68130 Douglas
<br />Z 9a. RESNENCEStATB 96. COUN7Y I 9c. CITY OR TOWN
<br />�
<br />�, Nebraska Douglas ' Omaha
<br />. ea. s�raaEer aau nwu��re e� arr. rro. er. � caoe s nrsroe cm urunrs
<br />�
<br />17475 Frances Street 88130 � Y� ❑ Na
<br />� 10a. MARITAL STATUS AT TIME OF OEATH ❑ Mercled ❑ Never dlart�ed 1Ub�. NAMH OF 8POU8E (First, Middle, Lest,. SuRix) fl wUe, give maklen �mme.
<br />� Martled. 6uf separeted � Wldoavad ❑ o�.o.eea ❑ u��owo
<br />�' 11. FATHER9-W1ME (Ftrat, NlMdte, Last, SuHdc) 12. MOTHER'9-NAME (Fbsf, Mtdd�e, Nlalden 8ummrte)
<br />E
<br />t
<br />@ John Still Ma eret Lindse
<br />m 73. EYER IN US. ARMED FORCE87 6fve dates of aervice H Yea 74a. fNFORMANT-NAME �- 14b. RElATlONSItIP TO DECEDENT
<br />F
<br />�reB, No,mUnk.) (�o Steve Sumnlck Son
<br />18. METHOO OF DISPOSITION 18a. Et�ALMER-SIONATURE 186. IJCENSE NO. 18c. DATE �EO Dey, Yr.)
<br />�evrW ❑DenaUon
<br />��� ❑��� Z December 18, 2010
<br />❑Re �� ❑ �� 8 � %) 18d. CEMETERY. CRFJNATOR OR OTHER LOCATION CITYlTOWN STATE
<br />Prospect Hitl Cemetery of Elkhom Omaha `Nebraska
<br />17a. FUNERAL HOME NAME AND MAILINO ADDRE89 (Street, Ctty m Tmm, State) 17b. Ztp Cade
<br />Reichmuth Funeral Home, 21901 W. Maple Road, PO Box 87, Omaha, Nebraska 68022
<br />CAUSE OF DEATH See instructlons and exam les
<br />1 P 6 En1er Bre ghatn o►erente . dkaaeea, q�Juriea. or aompilmtlare-that dltecUY aeueed tlre deeth. Do NOT eMer Iermind evsMs e�mA es eaNlm artes4 =�APPROXXm11ATE INTERVAL
<br />reeP��oN arrea6 m rantriaular ObrnlaUon w8hout ehowln0liw eUotogy. DO NOT A9HRL+IMTL+ EMar onnr a�e oavas on e Btre. Add edtQtlonel Mas qnea�eaty.
<br />N
<br />IMMEOIATE CAUSE: � ormet to dealh
<br />IMMEDIA'R CAUSE (Fl�rei 1's � v , � �� ( ` ` n l � • � � �� �- S � � � �
<br />dlaeaseorcondHlonresuldng a) v q � IJ�
<br />m a�m�
<br />DUH TO, OR AS A CONSECUENCE OF: = oimet to death
<br />Saquen8atty Iist comlidnrre. tt b � ►� e�,�.t Y 1 � � i �' ���
<br />, arpr, leeding m the eeuse Ilated 1 J
<br />on Me a DUE TO, OR AS A CONSEGIENCE OF: ; orreet to deafh
<br />• s
<br />:
<br />E�er ftm UFmERLYWO CAUSE �)
<br />� {disemme m h�Jury dm! fnitieted . �
<br />tire eveMS r�ulU� In deaWj DUE TO, OR A8 A CONSEQUENCfi OF: .� o�mst to deeth
<br />LAST
<br />� i .
<br />18. PART 0. OTHER SIOMFICANT CDNORIONB-Cortditb�re coM�ibutl� W the death but not resultirtg ln the uraierlping cauae gWen M PART L 19. WAS b7E0fCAL EXAMINER
<br />. OR CORONER CONTACTED7
<br />a Q(, r/ 1� (� �i' O� Lcl-++o
<br />W 20. IF FEMALE: 21s. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOP9Y PERFORMED7
<br />Y.
<br />F ot pragnant arithin past qeer �ml ❑ HomtcWe ❑ OrherlOperator �. YE8 0�
<br />� ❑PregtmM at tbne ot death ❑ Accfderrt ❑ PeMittg Imreatigadvn ❑ Paseenger 21d. WERE AUTOPSY FINDtNOS AVJU1118LE
<br />� ❑ NM prep�reurt, but pregmaM withln 42 deye of deetA ❑ Sukide ❑ Cw�d rrot be determhred ❑ Pedeatrtan TO COEAPLETE CAUBE OF OPATH7
<br />a � Not preg�nt, but pregnant 43 deqs to 7.yea► 6efoie death ❑ Otltar {BpecHy) � yEg �p� �..
<br />� QUnknsvm B pregnaM wltMn ttre past year
<br />O.
<br />0 22a. UATE OP INJURY (Mo„ Uay, Yr.) 22b. TIINE OF INJURY 22c. PLACE OF INJURY-At home, farm, street, tactory, office bulldb�g, co�truedon ake, etc. (Speciy)
<br />U �
<br />m
<br />m 12d. INJURY AT WORK? Z2e. OESCRIBE HOW INJURY OCCURREO
<br />!�-
<br />❑ YE8 ❑ NO
<br />22L LOCATION OF INJURY - STREET 8� NUAABER, APT. NO. CITYRdWN � STAT@ � � ZIP CODH
<br />23a. bATE OF DEA7N (b1o., Day, Yr.) 29a OATE 910NED (AAo., Day, Yr.j Z4b. TIME OF OEATH
<br />� � � �( � F. ��� m
<br />�} 23b. DATE SIGNED (Mo Day, Yr ) . T3e. TIME pF DEATH ' .. ���� T4c. PRONOUNCm DEAD (MO., oey, rr.) aaa. �m+� raorrouNCEO o�o
<br />E o ,�`.',�`.(,t7 ,:° '` " ' rD� m Ey� m
<br />� 23d, Tp the'trr�t rilv e� n,�leurcB� attNe Uirte, date and place ���� 24e. On flre basis of eocmnMadon malior ImeatlgaHon, in mq opbdon deeth oewrted
<br />�� c�rtd due M1fie'����e ;"� '�91g�a� e) ,$ 0 � et the l(me, date arni place and due to tlte eause(e) stated. (S�g�mdrta md Title)
<br />o „ � �� ,._� $ , � � i p
<br />� .oa � a�� '1 F�s� , ��' ��� ��""�� h t1
<br />� � �s
<br />28: q(D 74�C�C0 U$ O 1� tO TM6 OEA Q, �.b �' 2$a. H�69 OROAN OR T198U8 DONATION BEEN CONSIDERE�7 28b. WA9 CONSENT GRANT�7
<br />a y ' �
<br />D res � s _��] PpOBA9�;Y�, �] UNRN6WN �` '' [� YES [�_ Not Appticahte tt 28a ts ND ❑ YES ❑ NO
<br />2�,-,N�;i 6EilTIFI&(t-�plil'SIC�AN� hHN$�CIAM A8818TANT, CDRONER'S PHYSIC44N OR COUNTY ATTORI� (Type or P►int)
<br />Y r i.v�-r-Tpv��:. �. M1� t . .
<br />y . .
<br />.� L -� � .� t , q , � i °�0� . - L�-ti,'S.�?.S ►.c\� ,M�°vti � �V z t3U
<br />28a R�Q(BTt�R'S $IOMAf�1RB" `� �` o . � _+� 28b. DATE FILEU BY RE069TRAR (Mo� Dey. Yr.)
<br />� t' = A•-«--���,{sa� � . _ _�y �j � � ���o
<br />c..«r �
<br />e a t :< �` ,r . .
<br />� r -,
<br />, S $ .�� G "&i Q i .
<br />��'�+ r ro�' r : ? .
<br />.''T`�%s ce��es `tlii`'s document t.o be a tn.ie copy of an origi�al record on file with Vita1 Statistics,
<br />. Doug�as '�ounty Health Dep�, Omaha, Nebraska.. Certified copies must have a raised seal in the
<br />area to the left. Reproduction of this green eertificate are nat legal copies.
<br />� pEC 14 Z� 010 � �, �
<br />Date Issued: ' Regis[�ar• `
<br />
|