|
STATE OF NEBRASKA .
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH�9AfD�Y[!!�RlV �ERVIG���:IT -CERTIFIES
<br />THE BELOW TO BE A 7RUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASlCA Q�/?L(I��TI,l9�lI�T�O,F H�A�i;H LiIVD
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR: bl`TAC RE�ORD$"'' �'; ��� ,� F _'
<br />�'� _ �- A►1 j(�' � �
<br />DATE OF ISSUANCE ,, �� , ' �-1 � L���r _ ,
<br />5��111L�' S. CfIOQE'� ;`:� �r ��
<br />11/10/2011 ,�s�.�ran�s�r���Z�,r�rri.� f, �: _ -
<br />LINCOLN, NEBRASKA
<br />20110�842
<br />� �,,.�; t: ,
<br />, a,
<br />° .•.• _ � �
<br />; ,; } .�•,� ,- F , � r, �s :.-�
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER�CE'�,� '�' '�' ���!' '° :t� �P .��' 11 03690
<br />CERTIFICATE OF DEATH , _
<br />1. OECEDENTS-NAME (Flrst, Middle, , Last, Su(tbc) 2. SEX ' 3. tlA7EOF�DEATH (Mo., Day, Yr.)
<br />Marcia Lynne Carmann ' Female - `'=1�1oVember 4, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AOE • Laet Birthday b. UNDER 1 YEAR 6c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />° (�'► MOS. DAYS HOURS MINS. _
<br />Keamey, Nebraska 61 July 13, 1950
<br />T. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />505 ��� � InpaUeM QTHE� ❑ Nuraing Home/LTC � Hosplce Faclilty
<br />81i. PACILIIY-NAME (If rrot Institution, gNe street and mimber) � EWOutpaderrt ❑ Decedent's Home
<br />�
<br />� Saint Francis Medical Center ❑ ooa ❑ oiner {specny►
<br />c�
<br />� 8c. CITY OR TOWN OF DEATH pnclude Zip Code) Bd. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 8a1. RESIDENCE-STATE , 8b. COUNTY 8c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />� 8d. STREET AND NUMBER e. APT. NO. !9(. ZIP CODE 8g. INSIDE CITY LIMITS
<br />a 518 S. Clay S� 68803 ��s ❑ No
<br />'° 1Qa. MARITAL STATUS AT TIME OF DEATH � Martied ❑ N9ver MarHed 10b. NAME OF SPOUSE (First, Middle, Last, ' Suffix) H wffe, give malden mame
<br />� Married, but aeparated ❑ Wldowed ❑ Divorced ❑ Unknown
<br />� ❑ Larry Carmann
<br />� 11. FATHER'S•NAME (Firsf, Mlddle, Laet, Suffix) 72. MOTHER'S•NAME (First, Middle, Malden Sumame)
<br />m Milford Gulleen Arline Hanson
<br />�' 13. EVER IN U.S. ARMED FORCES? Give dates of aervlee Ii Yes. 74a. INFORMANT•NAME 74b. RELATIONSHIP TO DECEDENT
<br />E
<br />$ �r�, No, or un�c.) No La Carmann Husband
<br />� 78. METHOD OF DISPOSff10N 78a. EMBALMERSIGNATURE 18b. UCENSE NO. 78c. DATE (Mo., Day, Yr.)
<br />F ❑ BuHal ❑ Do�wtlon
<br />'� Not Embalmed November 8, 2011
<br />� Crematlon Q Eirtombment 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />p Removai ❑ aner �speeiry� Central Nebraska Cremation Senrices Gibbon Nebraska
<br />7Ta. FUNERAL HOME NAME AND MAILINq ADDRESS (Street, City or Town, State) 17b. Zfp Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE F DEATH See Instructions and exam les
<br />1& PART L EMerthe chain ot eveMS--0isesaes, in)mies, or complicatlonsdhu GUeWy caused the death. DO NOT e�rter tenNnal eveMS such aa nrdlae arrest, ; APPROXIMATE INTERVAL
<br />respiratory arrest, or ve�ieular flbrNatlon wfthout ehowl� the aGOtopy. DO NOT ABBREVIATE. Faner onty o�re cause on a Ihre. Add aAdlUanal U�res it ireceseary.
<br />IMMEDIATE CAUSE: ; o�et to death
<br />�e�ou+re cause c� e) Adenocarcinoma Lung Cancer, Metastatic E 1 Year
<br />dlseaee w condtUon reauitlnp
<br />�" d �� DUE TO, OR AS A CONSEGUENCE OF: : cnset to death
<br />9equentiany Ilst cond�tlona, U b) '
<br />anY� teadi� to the cauw Ilated '
<br />on Me a DUE TO, OR AS A CONSEpUENCE OF: ' oriset to death
<br />F.nter the UNDERLYING CAUSE C �
<br />(dl�ase or In1�Y Umt InitlateU
<br />the eveme resuVdnp In deatn) DUE TO, OR AS A CONSEQUENCE OF: : Onset to death
<br />� d)
<br />18. PART II.OTHER SIGMFlCANT CONDITIONS-Conditiorre contributing W the death but not resulti� in the underiying eause given In PART i. 18. WAS MEDICAL EXAMINER
<br />Radiation PneumOnitis OR CORONER CONTACTED?
<br />a , ❑ YES � NO
<br />W 0. IF FEMULLE 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMEDI
<br />�
<br />� � Not pregna�rt wlthln past year � Naturel � Homlcitle � OrivedOperetor �� � NO
<br />W Pregna�rtattlmeotdeatM1 �Paesen9e*
<br />V � AccideM � Pentlln0 ���eatiBadon
<br />� � Na vreenant. but wgenaM wnhin as daye w death � Peaeatrtan 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />SulWde Could nM be tletermUred
<br />TO COMPLETE CAUSE OF DEATH?
<br />� Not WeBne�rt, but pregna�rt 49 daye to 1 Yesr betore death � ourer ts ❑ ❑
<br />� �UnknownNpre9�aMwNhinthepastYear . , YES NO
<br />� 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, office bullding, constructlon slte, etc. (SpecHy)
<br />$
<br />.� 2�d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F�
<br />❑ YES ❑ NO
<br />2�L LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />23a, DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (MO., Day, Yr.) 246. TIME OF DEATH
<br />S" � November 4, 2011 � � � •
<br />� ' E� 23b. DATE SIGNEO (Mo., Day, Y�.) 23c. TIME OF DEATH �� a� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />s� Z November 7, 2011 06:44 PM o
<br />$�� � 3d. To the beat oT my knowlad8e, death occurtetl at tha time, date emi place $ � 24e. On the baeb oi exaMnatlon and/m Imestigatlon. in my opinion death occurteG at
<br />��- and due to the cauee(s) etated. (Signature antl Title) ��$ the dme, tlate and plaee and due W the cauae�s) etated. (Sipnature and TIUe)
<br />~'� Travis S. Hageman, MD ~ g a
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTEDT
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Appllcable H 28a Is NO ❑ YES ❑ NO
<br />. , TI7' RE IF P I T 1 R ype or dM
<br />Travfs S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />2. REGISTRAR'S SIGNATURE `__ 28b. DATE FIIED BY REGISTRAR (Mo., Day, Yr.)
<br />7Q�/V
<br />� November 8, 2011
<br />
|