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STATE OF NEBRASKA - , � :;`
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF,HEALT!-fAl�(f�WU�91J�,5'i, Rl/,TCE�; ,l7' CERT1
<br />TME BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASICA=�L'� �� �-lEAL7'I-�AND '
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR Vl�i�l�l�E�ORDS.. "- �� �
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<br />DATE OF ISSUANCE /•
<br />09/06/2011 � O�, � p'7 7 5 4 S
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<br />LINCOLN, NEBRASKA "' ' Ht
<br />STATE OF IVEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SEP
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<br />1. DECEDENTS (Flrst, Mlddla, Last, Suft6c) 2. SIX �� ,��[�d��'QF t�ax.�fnno., Day, Yr.)
<br />Margaret Mn Beran 'Fema�e < <"� �ugust30;°2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Birthday b. UND�R 1 YfAR 5c� NDER 1 6AY° '8. DATE OF BIRTH (Mo., Day, Yr.)
<br />IYB.) MOS. DAYS HOURS MINS:
<br />Grand Island, Nebraska 57 December 26, 1953
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />505-745411 OSPIT � InpaUent OTHE ❑ Nursing Home11.TC � Hospice Facltlty
<br />8b. FACILITY-NAME pf not Instltutlon, give street and number) � ER/OUtpatleM ❑ Decederrt's Home
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<br />� Nebraska Heart Hospital ❑ aoA ❑ otner �sPe�ity�
<br />� 8c. CITY OR TOWN OF DEATH (Include 21p Code) 8d. COUNTY OF DEATH
<br />o Uncoln 68526 Lancaster
<br />� ea. RESIDENCE-STATE 8b. COUNTY 9c. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />� 9d. STREET AND NUMBER 9e. APT. NO. 9L ZIP CODE 9g. INSIDE CffY LIMITS
<br />� 3106 West13th ' 68803 � YES ❑ No
<br />'� 10a. MARITAL STATUS AT TIME OF DEATH Q Married ❑ Never Married 10b. NAME OF SPOUSE (First, Mtddla, Last, Suffix) If wHe, gNe malden mame
<br />� ❑ MarHed, but separated ❑ Widowed � DWorced ❑ Unknown
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<br />� 11. FATHER'S•NAME (First, Mlddie,, Last, Sufflx) 12. MOTHER'$-NAME (First, Middle, Malden Sumame)
<br />m Joseph Francis Beran Lucille Marion Fortin
<br />�' 13. EVER IN U.S. ARMED FORCES? GNe dates of service H Yes. 14a. INFORMANT•NAME 14b. REI.ATIONSHIP TO DECEDENT
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<br />$ �res, No, or unic.) No ' Pamela Kendall Sister
<br />� 18. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE 164. LICENSE NO. 18c. DATE (MO., Day, Yr.)
<br />F � Burlal ❑ oonauon Paul A. Seger 1425 September 2, 2011
<br />❑ CremaUon � Entombment 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />� Removal ❑ Other (SpecHy)
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />77a. FUNERAL HOME NAME AND MAILINO ADDRESS (Street, Ctty or Town, Sfate) 17b. Zip Code
<br />Atl Faiths Funeral Homa, 2929 S. Locust Street, Grand Isiand, Nebraska 68801
<br />CAUSE OF DEATH See Instructions an exam les
<br />18. PARi I. EMer the ahain oi eveMe-diseasas, InJurles, or complicatlone-that tlirectly caused the death. DO NOT eMer terminai eveMe such as cardlac arrest, ; APPROXIMATE INTERVAL
<br />respiratory artest, or veMriwlar flbrillaFlon wNhout ahowin8 We eUology. DO NOT ABBREVIATE. Enter onty one cause on a Ilne. Add addidonal Ilnes It irecessary.
<br />IMMEDIATE CAUSE: ; onset to death
<br />unmeea� cause �fl�i a) Congestive Heart Failure E Years
<br />disease or condHlon resuldn8 ��. �
<br />�n death) DUE TQ OR AS A CONSEQUENCE OF: ; onset to death
<br />s�,�a�ae�ty �� ��a�ao�, n b) Coronary Artery Disease ; Years
<br />anr� ieadmg ro nre muae i�ea
<br />on Une a. DUE TO, OR AS A CONSEQUENCE OF: � onset W death
<br />E�rter the UNDERLVIN6 CAUSE ��
<br />{di�ase or InJury Umt InlGated
<br />the eveMs reauldng In death) DUE TQ OR AS A CONSEQUENCE OF: � onset to death
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<br />18. PART U. OTHER SIGNIFICANT CONDITIONS-Condltions contributing to the death but not resulUng In the undedying cause gfven In PART I. 18. WAS MEDICAL FXAMINER
<br />OR CORONER CONTACTED7
<br />� ❑ YES � NO
<br />W 20. IF FEMALE: 27a. MANNER OF DEATH 21b. IF TRANSPORTATiON INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />� � NotpreB�M��npaetyaar � Natursl � HomlGde � DriverlOperator � �s � NO
<br />W PreB�M at tlme M death � Pmesen8er
<br />V ❑ � AWdaM � Pending �mesdgation
<br />� Not pregnaM, but pregnaM withln 42 tlaya ot death � Pedastrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />a Suldde CaWO not be determl�red �
<br />❑ ❑ TO COMPLETE CAUSE OF DEATHI
<br />� NM pre8�a�rt. but PreBnaM 43 tlays to 1��yea� betore death � Other (SP��Y) 1--
<br />� � Unknown H pragnam wkhin the past year � �' � � 0-. � - � u� h0
<br />�' 22a. DATE OF INJURY (Mo., Day, Yr.) ' 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, etreet, tactory, offlce building, cortstruction site, eta (Speclfy)
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<br />a 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />�' ❑ YES ❑ NO
<br />22f. LQCATION OF INJURY - STREET & NUMBER, APT.NO. CITYlI'OWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) ` 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />.� � August 30, 2011 S� r
<br />� 23b. DATE SIGNED (Mo., Day, Yr.) 2Sc. TIME OF DEATH ���} 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />$� o Au Ust 31, 2011 01:30 PM � � a z
<br />9d. To the beat ot my knowledge, deatA occurted at the tince, date and place �5 �� 24e, On the basfa oT exeminatton end/or invesdgatton, in my opinlon death occurred at
<br />� 8 and due W the ca u a e(s) etated. (Si gnature and Tkle) � g� the tlme, data and place and due to the cause(s) smted. (Slgnature and TtUe)
<br />$ Harpaul S. Bajwa, MD g o
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH4 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED7 26b. WAS CONSENT GRANTEDI
<br />❑ YES ❑ NO ❑ PROBABLY � UNKNOWN � YES ❑ NO Not Appllcable H 28a Is NO ❑ YES � NO
<br />27. NAME, TITLE AND D SS OF CERTIFIER (PHY I , HYS C I T, C R ER S ITYSI O OUNTY ORNEI� ype or PriM
<br />Harpaul S. Bajwa, MD, 7440 S 91st St, Lincoln, Nebraska, 68526 '
<br />28a. REGISTRAR'S SIGNATURE ����+''t. �-+da�.G�s,,,,� , 28b. DATE FILED BY REGISTRAR (Mo, Day� Yr.)
<br />September 2, 2011
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