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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBR.4SKA DEPARTMENT OF HEALtH AN1�I�C�I�V SE'R�/�C�;�,. IT �ERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASK,�9EPAR i EN�` �� E��H AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VI�"AL R�D�`� �;? �9
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<br />DATE OF ISSUANCE µ, , , � • ��
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<br />2 0110 8 5 9 4 ��I�a� � �� Rir� %..
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<br />LINCOLIV, NEBRASKA H(l�1,4RI, SEJ2VI��5 ' �r � . r;�
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVId' S� � �,.�,
<br />ERTI CATE F DEATH �`'�`'' 1 % ° ��� ����-�.�
<br />1. DECEDENTS-NAME (Fint, � Middle, . Laat, Suffix) � 2. SEX � �i.�A F DEATH �(i�o ;'Bay,YrJ � .
<br />Ma Leora West ' �� � Y+ `�� a �
<br />Female October 8, 2011
<br />. . � A qTY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH . 6a. AGE-Last Birthday 5b. UNDER 1 YEAR Bc. UNDER 7 DAY 6. DATE UF BIRTH (MO., Day, Yr.) � . � �
<br />. � � � � � (Yrs.� MOS. � bAYS � HOURS MIN& . �. . . � � � � � �
<br />Vance, Alabama 68 April 22, 1943
<br />7. SOCIAL SECURI7Y NUMBER . . 8a. PLACE OF DEA7M . . . . ' � . � . . � � �
<br />O Q2O-5Q.-6J96 HOSPITAL: � InpaHeM � ER• Q Nuning Home/LTC .� Hospice Faciliry
<br />V 8b. FACIUTY-NAME (H not Instltution, �give atreet and number) �� ER/Outpatient � DecedenCa Home . � . . �
<br />� Saint Francis Medical Center ❑ �A ❑ome.�s���r��
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<br />� 8c. CITY OR TOWN OF DEA7H (teclude Zip Code) � . � 8d. COUNTY OF DEATH � � . . � � . .: .
<br />W Grand Island 68803 HaA
<br />� ' � 9a. RESIDENCE•STATE � � 9b, COUNTY . 9a CITY OR TOWN � � � � � � � � � �
<br />�� � � � � � . � �
<br />.. w . . . . . . � . . � . . . . �
<br />�, Nebraska Hall Grand lsland .
<br />. � 9d. STREET AND NUMBER � . � 9e. APT. NO. � 9f, 21P CODE �� 9g. INSIDB CITY:LIMIT� �� ��
<br />!� 412 Eisenhower Drive 68803 � Y� ❑"�
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<br />� .10a. MARI7AL STATUS AT TtIOfE OF DEA7H � Martied �� Never Marrled 70b. NAME OF SPOUSE (First, Mtddle, Last, . SuH3x) If wlfe, give� malden nama � � �.� � � �. . �,
<br />� Martled, but se arateq W{dowed Divoreed � � � � � " � � � � � � �
<br />� ❑ v, ❑ ❑ ❑ unknown gObby Hugh West
<br />a 71. FATHER'8-NAME �(Firsq Middte, Laeq Suffix) � 12 MOTHER'S-NAME (Flrsq Mlddle, � Maiden Sumame)
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<br />. O . � . .. . . . .
<br />� Neison Mur h Ma E Mathews
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<br />07 �� 13. EVER iN U.S ARMED FORCEST Give dates ot servlce if�Yes. 14a. INFORMANT-NAME - � � 14b�. RELATIONStNP TO DECEDE�IT � � �- �
<br />O� � � � . . . . . . _ .
<br />� (Ves, No, or unk.) No � � � � BObb Hu� h West � � �Husband � � �
<br />�� 15. METHOD OF DISPOSITION 16a. EMBALM@RSIGNATURE t6h. IICENSE N0. 16c. DATE (Mo., Day, Yr.) . . .. � ��� �
<br />p Bune1 p DOna00n Not Embalmed October_11, 2011
<br />. . ,. �CremNlon �E�rtombmem � . . . . . ..
<br />� � . �Removti� � ❑oMer(speNry� 76d, CEMETERY, CREMATORY OR OTHER LOCATION CITYlTOWN � � � � STATE . � � �
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />� . 17a. FUNERAL HOME NAME AND MAILING ADDRESS (8treet, City or Town, State) � � � �� � � tTb. Zip Cotle � �. �� �
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH (See instructions and exam les
<br />� tt. PAR7 L Enur the ehaln W ewnn - tliseas�s, injudes, or compliaNOns-t�at dircctty cauaed the tleat�. DO NO7 snter terminal aventa wch es pMlac arresq � � APPROXIMATE INTERVAC � �
<br />rcapiratory arroat, or wmACUlar 1i6dllatfon withotit showing the etiology. DO NOT A68REVIATE. Enter only one cause on a �i'ro. Atltl aGEttional Iinea H necesaary. : � � � � � � �
<br />. � � � IMMEDIA7E CAUSE: � � onaet to deaM � � �
<br />� . . . . .. ..� .. . � . . ... . . . ..
<br />IMMEDIATE CAUSE (Final y� ' � . /1 y . � � . � �� � �
<br />disease or condition rosultlng a) � Kel�� ' y �•f--n + I � � �.�o _ . � . . � I 1 J� /� e k'. .. � , �
<br />in death) � � J � !/il 1 V�.n v u Y . . .
<br />� DUE TO, OR A CONSEQU E OF: . � � . . � omet to death . . . � � . � � � �
<br />Sequenflaily Iist contlitions, H /+ /� � � � [� � � � � . �
<br />any, Ieading to the cause Iisted b � �e� S�� v ��'� `��� - . " � � . � ��J ,. . . . . �
<br />� on line a � �� � DUE T0, OR AS A CONSEQUENCE OF: � � _ �. � � onset to deaM � � � � � � � .
<br />. . . . . . � . . � . .
<br />� � � . . . . i � .. . � . .
<br />Enter the UNDERLYING CAUSE �) � � � � � � � � � � � �
<br />. (disease or injury that Inittated � � . � � � � � � � �
<br />� the eventa resulqng in death) � �UE TO, OR AS A CONSEQUENCE OF: � . y onset to tleath � � � -. ..� �� .
<br />lA3T � . . � . - . �� � . . . . . . .. .
<br />- � . .. � .. . . ,
<br />. . . . . i . . . .
<br />d) . . � � . . . . �. . .... . ..
<br />� 78. PART 11. OTHER SIGNIFICANT CONDITIONS-Conditfons conUibutlng to the death but not resulNng In the undeAyfng cause given In�PART L � 19. WAS MEDICAL EXAMINER �.. . �
<br />� � � � � . � � � OR�CORONERCONTACTED7 � � .. � . ' . .�
<br />� .. . YES �, [] Np � � .. � . �
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<br />W 20. IF FEMALE � � . 21a. MANNER OF DEATH 21b. IF TRANSPORTATION. WJURY 21c. WAS AN AUTOPSY PERFORM@D? �
<br />Y. . � . . . . . .
<br />� � �]Not pregnent wiMin past year '� Netural ❑ Homtcide ❑ DrivedOperator � YES ❑� NO� � � � � � .
<br />W ❑ Prognant at time of death . � Aecident � Pending Investigation ❑ Pasaenger � � �
<br />V 21d. WERE AUTOPSY FINDINGS AVAILABLE � � . -�
<br />, ❑Not pregnant, but pregnaM.within 42 daya of death ❑ Suleide ❑ Could not be determined ❑ Pedeatrtan � TO COMPLETE CRUSE OF DEA7H9 �. � .� � �
<br />� a ❑ Not pregnant, but pragnant 41 days to 7 year before death ❑ Other (Specify► . � � YES � � NO � �� � � �
<br />� QUnknownif pregnant within Me past year � � . � � � � � � � � � � � . �
<br />�G . . . ... . ..
<br />� 0 22a. pATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, streeq tectory, office Duilding, rnnatruction s@e, eta (Specifyj � ��. � . ��. �.�
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<br />m 22d. INJURY AT WORK7 22e. OESCRIBE HOW INJURY OCCURRED � � � � � �
<br />. O � � � . . � . � � .
<br />F' ❑ YES. ❑ NO . . � � .. � . . .. � .
<br />. 22f. LOCATION OF INJURY - STREET 6 NUMBER, APT. NO. CITYITOWN � STATE. � � � ZIP CODE .��. � � �
<br />23a. DATE OF DEATH (Mo.. Day, Yc) . ` Z 24a. DA7E 51GNED (Mo., Day, Yr.) 24b. TIME OFpEATH � . • ��
<br />aLL ctober 8 2011 a�z m
<br />.�' �� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH �} O 24c, PRONOUNCED DEAU (Mo., Day, Yr.) 20d. TIME PRONOUNCED�DEAD �. � � � . � �.
<br />£�z QCt. "tD 2011 •1 Am ��aZ m
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<br />° V 23N. To the best of my knowledge, death occurred at the time, date and place � w Z O 24e. On the basis of examination and/or invesHgapon, in my.op{nlon deatl� oecurrod� . � .�
<br />��� � and due to the causa�s) stated. (Signature antl Title) a� U at the time, date and place end dus to the cauee(s) sYated. (SignMUre and Tltlej , ..
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<br />� 25. DID TOBACCO USE CONTRIBUTE TO DEATH9 28a. HAS ORGAN OR TISSUE UONATON BEEN CON3IDERED9 26b. WA$ CONSENT GRANTED? � � � � �
<br />❑ YES . NO � ❑ PROBABI Y ❑UNKNOWN � YES � NO . Not Applicable H�28a �s NO . ❑ YE9 � � ❑ NO � �� .
<br />� 27. NAME, TITLE AND ADDRESS OF CERTIFlER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEYj (Type or PriM) � � � � � .� �.
<br />Suzanne Greenquist,D;,q.606 N. Minnesota Ave., Hastings, Nebraska 68901 ,
<br />. 28a REGISTRAR'3 SIGNATURE . � � 28b. DATE FlLED BY REGISTRAR (Mo., Day, YrJ . "
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