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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEA� OF THE NEBRASKA DEPARTMENT OF HE,9�,�H��f �(V"5�'R�s,"�T nE� TIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB,�IS,K�� �
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITOR4� FQ�t VS�f'A�' � � r
<br />�� �. � �� ," �
<br />DATE OF ISSUANCE t , e � .. < r ' ' A
<br />07/08/2011 'a��`Aiv��'r o �R � . '�� �°
<br />;���is�`ar� �c-�'�rst,��; �' �
<br />t��E�RTMFNT OF>f�fEALTH.i4A(� .��'
<br />LINCOLN, NEBRASKA HPJM�4�1P$��V,I�ES' ���a` � `�,� ,
<br />, „ , .,��1����`'�'��'� , ..� �
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE�� r'•••••�' �� (�• M � " �,� OZ�LZO
<br />IiCK I 1tlliAl t Vt UCAI l'1 'r y. °' u� y s --
<br />1. DECEOENTS•NAME (Firat, Middle, Last, SuHbc) 2. SEX �° ' 3. LlAL�`O�'DEATH (Mo., Day, Yr.)
<br />Ph Iis Gene Dryer Female June 24, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Blrthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF B1RTH (Mo., Day, Yr.)
<br />(Y►s•) MOS. DAYS HOURS MIN3.
<br />Merr(ck County, Nebraska 81 July 27, 1929
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />508-30-2789 I} p�PlTql, ❑ �npaUent OTHER ❑ Nuraing HomeILTC � Hospice Facility
<br />8b. FACILITY•NAME (If not Inatitution, glve atreet and number) ❑ ERtOutpaUent ❑ DecedeM's Home
<br />�
<br />� P�imrose Retirement of Grand Island ❑ noa � o�t,er �spectryWSSISTED LNING
<br />� Bc. CITY OR TOWN OF DEATH (Inciude Zip Code) Bd. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 8a. RE310ENCE�STATE 8b. COUNTY 8c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />� 8d. STREET AND NUMBER 9e. APT. NO. 9t. ZIP CODE 8g. INSIDE CITY UMITS
<br />�` 3990 W. Ca ital Av #106 68803 ��s ❑ No
<br />.0 10a. MARITAL STATUS AT TIME OF DEATH � Married � Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Sufflx) It wtfe; 8Ne malden name
<br />d
<br />� ❑ Married, but separated ❑ 1Nldowed ❑ Divorced ❑ Unknown Robert DryBf
<br />m
<br />� 11. FATHER'S•NAME (Flrst, Mlddle, Last, Suffix) 12. MOTHER'S-NAME {First, Middle, Malden Sumame)
<br />Julius Daberkow Christine Gerlach
<br />°' 13. EVER IN U.S. ARMED FORCE3? Give dates of aeMce H Yes. 74a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />$ �res, No, or unic.� No Robert D er Husband
<br />� 18. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. UCENSE NO. 16c. DATE (Mo., Day, YrJ
<br />F � Burtal ❑ oorrat�on PaMcia R. Cuman 1092 June 28, 2011
<br />❑ CremaUon 0 Ertom6merrt �gd. CEMETERY, CREMATORY OR OTHER LOCATION CRY / TOWN STATE
<br />� Removai ❑ otner �specKy> Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILIN(3 ADDRE89 (Street, CHy or Town, State) 77b. Zlp Code
<br />Curran Funeral Chapei, 3005 S. Locust St., Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See instructions and exam les
<br />18. PART i. Errter the ehaln ot eveMa-dlaeases, lpjudes, or compllcaUons4hat tlireetiy caused the death. DO NOT eirter terml�l avarhs euch as cerdiac erteat. ; APPROXIMATE INTERVAL
<br />respiratory artest, or ventricular flbrlllaGOn without ehowtng the eUoiogy. DO NOT ABBREVIATE. EMer only oire cause on a Ilne. Add addWonal lurea If neceseary.
<br />IMMEDUITE CAUSE: ; or�et to death
<br />IMMEDIATE CAUSE (Final 8) Pancreatic Cancer With Regional MetastaUc D(sease � 3 Months
<br />disease or condfdon reaulUng
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: ; orreet t0 death
<br />3aque�rtially ilat condkione, ii b) ;
<br />em� �ding to the cauae Iisted t
<br />on I�ne a. DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />EMe� the UNDERLYING CAUSE C )
<br />(disease or InJury that Inttiatetl
<br />tne aveMs resmdne m deaui) DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />�nsr d) ;
<br />18. PART 11. OTHER SIGNIFlCANT CONDITIONS-Co�dlUor� contrlbuting to the death but not resuttlng in the undertyfng cause gNen In PART I. 19. WAS MEDICAL EXAMINER
<br />Diabetes, Coronary Artery D(sease, Hypertension, Benign Essential Tremor, Spinal Stenosis OR CORONER CONTACTED?
<br />� p ves p No
<br />W 20. IF FEMALE: 21a. MANNER OR DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />� � Not pregnaaf withtn past year � NaW rel � Homlcide � DrfvedOperator � YES � NO
<br />� �� PregnaM at tlme oi tleath � AccideM � Pending Inveetlgadon ❑�"ee�
<br />� � Not pregmaM, but pree� ��n 42 days ot tleath gW�e Could not be determined � Pedesv�e� 27 d. WERE AUTOPSY FlNDINGS AY/ULABLE
<br />'4 � Not pregnant, but pregnaM 43 � � TO COMPLEfE CAUSE OF DEATH?
<br />aaye m � rear oerore aea�n � ane. �saec�ryl
<br />� � unlmown Ii Pre9� �In the past year ❑ YES ❑ NO
<br />°' 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, Tarm, streat, factory, oftice building, constructlon sfte, atc. (Spectfy)
<br />E
<br />$
<br />.� Z2d. INJURY AT WORKT 22e. DESCRIBE HOW INJURY OCCURRED
<br />H
<br />❑ YES ❑ NO
<br />22i. 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 />.� June 24, 2011 ; .� �
<br />� 23b. DATE SIGNED (Mo., Day, Yr.) 23C. TIME OF DEATH �� k Y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� � Jul 6, 2011 02:10 PM �' 4 a z
<br />$ � . To the beat ot my knowied8e, death ocaurred at the tlme. date and place $ �� 24e. On tha besis of examinatlon endlor investlgatlon. in my opinion death oceurtad at
<br />�� entl due to the cause(s) statad. (Signature antl TtUe) ��� Ure tlme, date and place and due to the cauae(s) atatad. (Signature and TRIe)
<br />~� Kimberly A. Mickels, MD ~� s
<br />25: DID TOBACCO USE CONTWBUTE TO THE DEATH7 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />� YES � NO � PROBABLY ❑ UNKNOWN ❑ YES � NO Not Appticable if 26a Is NO ❑ YES ❑ NO
<br />, TITLE ADDRE OF CERT FI R PHY CIAN, Y IC ASSI T T, C R NER 3 P SIC OR CO NTY A E`� ype or Prhrt
<br />Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE �+ 28b. DATE FlIED BY REGISTRAR (Mo., Day, Yr.)
<br />July 6, 2011
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