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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEACTH AND HtIMAN;S'EIdVICES, 77" CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE N�B/2ASKA�p�R,61��N,��'.,�VT OF.J-IEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEG<IL DEPOSITORY F�R -U.I��f't R,��Q D
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<br />.;� ac `� ��
<br />DATE OF ISSUANCE
<br />� • � � � �-y,,�
<br />07/21 /2011 ����' . cooPER �, w�,
<br />2 0110 6 7 4� A�S.�STANT STA�"E''R�Gt'STkA,I� ,s
<br />�3E�IRTM�l1�'�'t�"F f��A�TH 61ND, � e�
<br />LINCOLN, NEBRASKA I-�UM.4{V S'�'fTI�G��.�.�.i ,,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SE�YIC�jS'. � " y�' � `,' ,;,�,� n � d ��
<br />GERTIFICATE OF DEATH ? "�'',,'�.'"L�°� T �,y! '�,:.• �` ` . '"_
<br />1. DECEDENTS-NAME (Flrst, Middle, Last, SuNix) 2. SIX' " �,+� � 9: DATE OF DEATH (Mo., Day, Yr.)
<br />�Mary Ellen Rupp � Femal�' u,,' °°� :F ° JUI�Y �4, 2Q1'1
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last Blrthday b. UNDER 1 YEAR 5c. UNDER 7 DAY ' 8: DATEOF BIRTH (Mo., Day, Yr.)
<br />��•1 MO3. DAYS HOURS M1N3.
<br />Omaha, Nebraska 71 January 25, 1940
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />50&40 HOSPITAL � InpaUeirt OTHER � Nursing Home/LTC � Hosplce Faclllty
<br />8b. FACILITY•NAME (If not Instltution, glve street and number)
<br />� ❑ ER/OulpaUent ❑ DecedenPa Homa
<br />� Tiffany Square Care Center ❑ ooa ❑ otner �sp�y►
<br />� 8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />c Grand Island 68803 Hali
<br />� 9a. RESIDENCE-STATE 8b. COUNTY 9c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL Sd. 3TREET AND NUMBER 9e. APT. NO. 9F. ZIP CODE 9g. INSIDE CITY UNOTS
<br />� 2822 Lakewood Cr 68801 � res ❑ No
<br />.� 108. MARITAL STATUS AT TIME OF DEATH � Married ❑ Never Married 10b. NAME OF SPOUSE (Firat, Middle, Last, SuHiu) if w(fe, gtve malden name
<br />� ❑ nnamed, nu� separacea � Wldowed ❑ o�vorced ❑ Unknown Robert Rupp
<br />d
<br />� 17. FATHER'S•NAME {Flrat, Mlddle, Last, Sufflu) 12. MOTHER'S•NAME (First, Middle, Maldsn Sur�wme)
<br />m Wllliam R Spencer Agnes Slegl
<br />°' 13. EVER IN US. ARMED FORCEST Olva datea of sarvice ti Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECE�ENT
<br />E
<br />$ �res, No, or umc.� No Robert Rupp Husband
<br />,� 15: METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Oay, Yr.)
<br />� ❑ eur�ai ❑ oo�eon Not Embalmed
<br />July 15, 2011
<br />� Crematlon Q EMombmeM 16d. CEb1ETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Spectfy)
<br />Central Nebraska CremaHon Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Sfate) 17b.21p Coda
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 68801
<br />CAUSE OF DEAT See instructlons and exam les
<br />18. PAR71. EMer fhs ahaln oi eveme•df�asea, InJuries, or complicationsdhat d�rectiy eaused the death. DO NOT eMer terminel aveMs euch ae cardlac arrest, ; AppROXIMATE INTERVAL
<br />raeplratory arreat, ar venVlwiar flbrlltation without shovring the edology. DO NOT ABBREYIATE. EMer only orre cause on a Iine. Add atlditlonal Iines N rreceseary.
<br />IMMEDWTE CAUSE: ; onset to death
<br />IMMEDIATECAUSE(flnal a]Anaplastic Meningioma ; 6 Years
<br />tlleease or wndlUon rBSUltlng
<br />�� d �� DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />SequeMlaliy Ilet condidone, N b)
<br />a�ry, leatlin8 to the cauae Ilatetl
<br />on mre a
<br />DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />Errter the UNDERLYINO CAUSE �)
<br />(disease or Inlury that Initlated
<br />the eveMe reaulnng in death) DUE T0, OR AS A CONSEQUENCE OF: � onset to death
<br />� d)
<br />18. PART II. QTHER SIGNIFlCANT CONDITIONS-Comlitions contributing to the death but irot resultlng In the urMerlying cause gNen In PART I. 18. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED7
<br />� ❑ YES � NO
<br />W O. IF FEMALE: 21a. MANPIER OF DEATH 27b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />'a
<br />� � Not PreBna�rt wfthln P�Y� [� �s„�i � xo�aae � omre�io
<br />W PregnaM et qme of death � Pae��er ❑�S � NO
<br />V ❑ � ACCide�rt � Panding Inveetigaqon
<br />� � NM pregnant, bue pregna�rt within 42 days ot death � PadeaMan 21 d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />'� � Not pregnant, but pregnaM 43 daye to 1 year betore death ❑$uiclde � Cowd not be tletermined ❑ � r (8��� TO COMPLETE CAUSE OF DEATH?
<br />� � Unknown It prepnaM wlthin the past year ❑ YES ❑ NO
<br />� 22a. DATE OF INJURY (Mo., Day, Yr.) ZZb. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, ofFice butiding, cortstruetlon sRa, etc. (Spectfy)
<br />s
<br />.� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />~ ❑ YES ❑ NO
<br />22f. 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. TIME OF DEATH
<br />.� � July 14, 2011 � � �
<br />�� Y 23b. OATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH �� Y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />g Z Jul 15, 2011 08:06 PM � d<�
<br />$ � . To the best of my Imowiedge, tleath occurred at the Ume, date and place $ �� p q p, p � � ry e 6 a s i s M e x a m i n a d o n a n tl/ o r I n v a e G g a tl o n, i n m y o p i n i o n d e a t h o c c u r re tl a t
<br />$� end due W the csuse(e) stated. (Stgnature and TIUe) ��$ the dme, tlate and place and tlue to the catwe(s) atated. (SlgnaW re and THIe)
<br />~ James W. Hervert Jr., MD '" ��
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS OROAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTEDI
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN � YES ❑ NO Not Applicabte ff ZBa is NO ❑ YES � NO
<br />2. E, TITLE ADDRESS OF RTIFIER (P ICIAN, S I AN , C RONER 5 P 5 R OUNTY A O El� (Type or rirrt
<br />James W. Hervert Jr., MD, 2115 N Kansas Avenue, Hastings, Nebraska, 88901
<br />28a. REGISTRAR'3 SIGNATURE � r 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />July 20, 2011
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