|
STATE OF NEBRASKA 201107729
<br /> WHEN THIS COPY CARRIES THE RA/SED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br /> SYSTEM,!T CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIG/NAL RECORD ON FILE WITH
<br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM,VITAL STATISPICS SECT/ON, WHICH lS
<br /> THE LEGAL DEPOSfTORY FOR VITAL RECORDS. ��,���� ��
<br /> DATE OF ISSUANCE I��
<br /> MAY 12 2005 ASSISTANT S ATE REGISTRAR
<br /> L/NCOLN,NEBRASKA HEALTH AND HUMAN SERV/CES '.
<br /> STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SL'PPORT �
<br /> CERTIFICATE OF DEATH �� �)�.,�47
<br /> ° �' 1.OECEDENT'S-NAME (Firel, Middle, Lasl, Sullix) 2.SEX 3.�ATEOFDEATH(Mo.,Day,Yr.)
<br /> � � Nadine Bly Female A ril 22 2005
<br /> ��-��! 4.CITY AND STATE OR TEHRITORY,OR FOREIGN COl1NTPV OF BIRTH 5a.AGE-lasl Birthday 56.UNDER 1 YEAR 5c.UN�ER 1�AY 6.�ATE OF BIPTH(Mo.,�ay,Yr.)
<br /> ��A (Yrs.) MOS. �AYS HOUflS MINS.
<br /> `i Malmo, Nebraska 60 Ma 10 1944
<br /> 7.SOCIALSECURITYNUM6Eq ' Ba.PLACEOF�EATH
<br /> �d L 507-56-7466 Hosairni: ❑inva�ien� �l€a ❑NursingHome/LTC ❑HaspiceFecility
<br /> ,���:y� Oh.FACIUTY�NAM1tE (II nol ins�itulion,give sireel end number) zz .
<br /> ���-� . ❑ER/Oulpalleni 1�3�ecedenl'sHome
<br /> ��y�W�= 1103 Fast Street
<br /> �tG� ❑�4 ❑Olher(Specily)
<br /> �i� Bc.CITYORTOWNOFDEATH IncludeZi Cotle
<br /> EYbS ( P ) Bd.COl1NTYOFOEATH
<br /> ��Wood River 68883 Hall
<br /> "�Z��� 9a1iESIDENCE�STATE B6.COUNTY �
<br /> ��f£ 9c.CITYORTOWN
<br /> `�y`�Nebraska Hall Wood River
<br /> �,s.
<br /> :;y���� Bd.STREEfANDNUMBER
<br /> �;;��,, 9e.APT.NO 9f.ZIPCODE 9g.INSI�ECITYLIMITS
<br /> �,'��� 1103 East Street 68883 m ves �No
<br /> . ��� 10a.MARITAL 3TATU5 ATTIME OF DEATH �Marrietl O Na�er Marrled 70b.NAME OF SPOl15E(Firsl,Middle,Lasl,Sullix)It wlle,give maitlen name.
<br /> '^'a� ❑MarrieQ bul separaletl O Wldowed ❑Divorced�Unknawn p�en Bly
<br /> E�'�
<br /> �' '�
<br /> �{� 11.FATHER'S-NAME �Firsl, Middle, Lasl, Sullix) 12.MOTHER'S-NAME (Firsl, Middle, Maiden Sumame)
<br /> �, �c3
<br /> Fred Odvody Helen Vaca
<br /> �'�, 13.EVERINl1.S.APMEOFORCES?Givedalesafservkeilyes. 14a.INFORMANT-NAME 7Ab.PELATIONSHIPTO�ECE�ENT
<br /> � �ves,�ao���k.> No Ken Bl Husband
<br /> ��� 15 METHO�OF�ISPOSITION 16 MER-SIGNATUPE 166.LICE SEN .� i6c.DATE(Mo.,�ay,Vr.)
<br /> I
<br /> � �eural ODonalion G� . ��� April 27, Z��rJ
<br /> ��
<br /> �.� ❑Cremalbn ❑Enlombment 1fid.CEM EqY,CqEMATO YOFOTHERLOCATIDN GTY/TOWN 3TATE
<br /> � :.�.'�� ❑Remwal ❑Othar(8peclly) �
<br /> .�-�- St. Mar s Cemeter Wood River
<br /> ,��r _ Y Y Nebraska
<br /> ,,.:F; 17a.FUNEFlALHOMENAMEANDMAILW�AODRESS(Slreel,CityorTown,State) 176.ZipCOde
<br /> �:Apfel Funeral Hame, 411 West 11th St., P.O. Box 126, Wood River, Nebrask 68883
<br /> .�..,: �s.'�"� "s�"�.���#�'":�p��� '`"•'�; �u'��F UE�AT"�'v,�u, r"f� . .:E. : _.s
<br /> g,�i 10.PAFTI.Emerlhe9hamolevenis dlseases,lnjurles,arcompliwllons--Ihafdirec�lycaused�hedealh.DONOTenlerterminalevenlssuchascardiacartesl, � APPROXIMA7EIMEFiVnL '
<br /> ���`$ respiraloryarresl,orvenlricularlibrillelionwilhoulsMwinglheetlology.�ONOTABBREVIATE.Enleronlyonecauseonaline.Addadditionailinesilnecessary. �
<br /> h
<br /> � IMME�IAT�AUSE: f r D � ansetlodeeih
<br /> ��' i �a� �/�" 1���-'�'��r'_ �'� l �T�.�e>> ��%��t.�' ' ��.v'�=�J.
<br /> IMMEDIATECAt15E Final �
<br /> '`�{en diseaseorwndillanresulling pUETO,ORASACONSEQUENCEOF:
<br /> �� i onsel lo tlealh
<br /> h��; Indealh) a � ��
<br /> � C�_�l/I.('/!��'•tt/L-!l� r�.��1. C[?.t� � �
<br /> ,h��` seyu�n�iyu��a�a�no�:,ir roi _ i �`�..t .��a�'�
<br /> ���.,, eery,lead'mgtolheeauselisletl oUETO,OFASACONSEQUENCEOF: I
<br /> '�,�"��qq; onlinea. - i onsettodealh
<br /> =1�f{-: En�erlheUNDEPIYINOCAlI3E __,_�
<br /> ,��,�('-,�! �diseaseorin'ryrylhelinitleted (c) � I
<br /> i^+'j+ Ihe¢vmisresullingindeath)
<br /> ���, � DUETO,ORASACONSEQUENCEOF. � � onsellodealh�
<br /> �;g� `� i
<br /> f��� (d7 I
<br /> p� 18.PAfiTII.OTHERSIGNIFICANTCONDITI0N5-COntlitionscontributingtolhedealh6ulnoiresullinglntheund¢rlyingcausegiveninPARTI. 79.WASME�ICALEXhMINER
<br /> `�p OR CORONER CONTACTED?
<br /> 'a.'.�5 ❑YES 9'NO
<br /> �'dk� -
<br /> ��::: 20.I�FFEMALE: , 21a.Mq EROFDEATH 21b.IFTRANSPORTATIONINJUPY 21c.WASANAUTOPSYPERFOHMED7
<br /> �'� 0�'Nol pas year ��urel OHOmicide ❑Ori�er/Operator
<br /> �p� pregnanlw'Ihin 1 . ❑YES El�
<br /> ��� O Pre9nantallimeoltleath ❑ACCIdenlOPendinglnvesligalfon �Passenger
<br /> ❑Nolpregnanl,bulpregnenlwllhln42daysoldea�h ❑Pedesiran p1d.WEREAUTOPSYFlN�INGSAVAILABLE70
<br /> '� ❑SUlcide OCOUldnolbedelermined
<br /> ❑Nolpregnant,hulpregnen143daysiolyearbeforedealM1 ❑Olher�Specily) COMPLETECAUSE�OF�DF-A'TH7
<br /> ���}' ❑Ilnknownilpregneniw'Ihln�hepaslyea: _ ❑YES �}I'fJD '
<br /> 1
<br /> �d 22eDATEOFINJl1RY�MO.,�ay,Yr,) 226.71MEOFINJURY 22c.PLACEOFINJURY-Alhome,larm,sireel,leclory,oillce6uilding,cansl�uclionsite,ela�5pecity)
<br /> ��f� m
<br /> H� 22tl.INJURYATWORK7 22e.DESCRIBEHOWIWURYOCCURFED
<br /> �'�''_'
<br /> ��
<br /> `,� ❑YES Q NO �
<br /> g`��i'. 22f.LOCATIONOFINJIIRY-STF7EET&NUMBER,APLIdO. . CIiY/I'OWN STATE ZIPCOOE
<br /> '�fy�,"�,
<br /> ^InA���
<br /> �'rr3��;�• _
<br /> 'r��9U 23a.�ATEOF�EAT (Mo,?y,yrJ,� �Uy 2qa.DATESIGNEO(MO.,�ay,Vr.) 24b.TIMEOFDEATH
<br /> a Cf ! a� fp
<br /> ��' y=J 23b.DATE5IG ED�MO.,Day,Yr�J 23aTIME0F0EATH-- y�k 24c.PRONOUNCE�DEA�(Mo.,Oay,YrJ 24d71MEPRONOUNCE�DEA�
<br /> ,rp��', D z � . )C6/ " i CJ CS .m• E y a z RI
<br /> ? �O
<br /> �1�3, vc 2sd.ioihebestolmyknrn�ledge.deelhoccurredalthelime,dateandplaco �w�� 24e.Onlhebaslsolexamina�ionandbrrnesllgalion,rnmyopinlondealhoccurretlat
<br /> �!`t_F F and due to Ihe cause�s)sl led (Signal re andTllle)� a�U Ihe 1 me,dale and placa and due lolhe cause(s)staled(Signature and Title�♦
<br /> �,,,��; a 1_ >_��.���Gf� 1_, ~�o
<br /> kS' 25.�IDT06ACCDUSECONTPIBUTETOTHE�EATH?
<br /> �.� �� �� 26a.HASORGANORTI55UEDONATIONBEENCONSI�ERE07 266.WASCONSENTGRANTED?
<br /> t � ❑yES C�i'NO ❑PROBABLY ❑UN NOWN ❑YES 'F:1'NO Not Applica6le if2ea Is NO �YES C1-id�
<br /> :p�; 27.NAME,TITLEAf�D9oop SOF�TIFIER(PNSICIAN,CORONER'SPHYSICIANORCOUMVATTOflNEY)�TypearPrim) 1 1 Op�l�1�KTJ-P��$-OR--9� '
<br /> n P
<br /> ;s,;,;; �f� �-°�- ?�i�&t. Francis Cancer Treatment Center Grand Island NE 68802
<br /> 2sa.REGISTRAR'SSIGNATURE J ( 286.�ATEFlLEDBYREGISTflAP(MO.,�ay,Yr.)
<br /> � �J• �iAY 9 2005
<br />
|