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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE_WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTMSEC770N, W141CH-IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE N• l'`�"'0_ - NV 19 200212194 _�.00P_ LINCOLN, NOB SKA �00 � HEALTH AND HU4fAN S9MVICES SYSTtil ' STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVIICES I -NANCE AND SUPPORT 7 1 VITAL STATISTICS _ O 1 L_ 7 % F CERTIFICATE OF DEATH 1 DECEDENT - NAME FIRST MIDDLE LAST 2 2. SEX 3 3: DATE OF DEATH /Month Day Yearl n Female N November 3 2001 4. CITY AND STATE OF BIRTH lit not in U SA.. name country/ 5 5a. AGE -Last Birthday U CD UNDER 1 DAY 6 6. DATE OF BIRTH (Month Day. Year/ (Yrs) 8 SD MOS DAY$ 5 5c. HOURS' MINS A Cairo, Nebraska ( 86 S August 27, 1915 7. SOCIAL SECURTIY NUMBER O 8a. PLACE OF DEATH 505 -64 -0105 H HOSPITAL Inpatient OTHER. ❑ Nursing Home 8b. FACILITY - Name /d not institution, give street and numbeirl E 3530 N. 150th Road D DOA ❑ Other t$pearty' 8c / Bd. INSIDE CITY LIMITS 8 8e. COUNTY OF DEATH //CH�IT° T Yes � No a H Hall 9a RESIDENCE - STATE 9 9b. COUNTY 9 9c. CITY. TOWN OR LOCATION 9 9d. STREET AND NUMBER (Including Zip Code) 68824 9 CD CO Hall C Cairo 3 3530 N. 150th Road Y Yes ❑ N° 10 RACE leg, While. Black American Indian. 1 11. ANCESTRY leg.. Italian, Mexican. German, etc) 7 . ® MARRIED ❑ WIDOWED 1 13 NAME OF SPOUSE Ill wde. give maiden name/ etc.(lSoeci ty,_ ( (Specify) �.^ N 72 . L'� Be 1 ' Y n g Co cl Z s 00 CIO ttrJ�. t� WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE_WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTMSEC770N, W141CH-IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE N• l'`�"'0_ - NV 19 200212194 _�.00P_ LINCOLN, NOB SKA �00 � HEALTH AND HU4fAN S9MVICES SYSTtil ' STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVIICES I -NANCE AND SUPPORT 7 1 VITAL STATISTICS _ O 1 L_ 7 % F CERTIFICATE OF DEATH 1 DECEDENT - NAME FIRST MIDDLE LAST 2 2. SEX 3 3: DATE OF DEATH /Month Day Yearl Lucille Kath n &ellamy F Female N November 3 2001 4. CITY AND STATE OF BIRTH lit not in U SA.. name country/ 5 5a. AGE -Last Birthday U UNDER 1 YEAR U UNDER 1 DAY 6 6. DATE OF BIRTH (Month Day. Year/ (Yrs) 8 SD MOS DAY$ 5 5c. HOURS' MINS A Cairo, Nebraska ( 86 S August 27, 1915 7. SOCIAL SECURTIY NUMBER O 8a. PLACE OF DEATH 505 -64 -0105 H HOSPITAL Inpatient OTHER. ❑ Nursing Home 8b. FACILITY - Name /d not institution, give street and numbeirl E 3530 N. 150th Road D DOA ❑ Other t$pearty' 8c / Bd. INSIDE CITY LIMITS 8 8e. COUNTY OF DEATH //CH�IT° T Yes � No a H Hall 9a RESIDENCE - STATE 9 9b. COUNTY 9 9c. CITY. TOWN OR LOCATION 9 9d. STREET AND NUMBER (Including Zip Code) 68824 9 9e INSIDE CITY LIMITS Nebraska H Hall C Cairo 3 3530 N. 150th Road Y Yes ❑ N° 10 RACE leg, While. Black American Indian. 1 11. ANCESTRY leg.. Italian, Mexican. German, etc) 7 . ® MARRIED ❑ WIDOWED 1 13 NAME OF SPOUSE Ill wde. give maiden name/ etc.(lSoeci ty,_ ( (Specify) �.^ N 72 . L'� Be 1 23 IMME E CAUSE (ENTER ONLY ONE CAUSE HER UNE FUH 1al. ID). ANU (CI) Interval oetween onset and dears PART tal DUE TO, OR AS A CONSEOUENCE OF Interval between onsel and deam I (bl i DUE TO, OR AS A CONSEQUENCE OF Interval between onset and Beam I � IrI I 1 1 i 1 OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS, EXAMINER OR CORONER? (Ages 10 -54) Yes No Yes No Yes No 26a. 26b. DATE OF INJURY (Mc. Day. Yr) 26c. HOUR OF INJURY 2CA. DESCRIBE HOW INJURY OC URIID ❑ Accident Undelermmed M ❑ Suicide R Pending 26e. INJURY AT WORK 261. PLACE OF INJURY - At home. farm, street. factory 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE ❑❑ ❑ o ce bmlding. etc. /Specify/ Homicide Investigation yes No 27a, DATE OF DEATH tMo.. Day Yr.) 28a. DATE SIGNED (MO.. Day. Yr) 281b TIME OF DEATH November's, 2001¢ M 27b. DATE SIGNED /M . Day. Yi. 27c. TIME OF DEATH d a > 2Bc. PRONOUNCED DEAD IMO. Day, Ycl 28d. PRONOUNCED DEAD 'Hour) i Novembe 1$ X00 10:05 am Mwz° - M 27d. To the best of my kno led JCCalt time ate and place and due to the ° 28e. On the basis of examination and,or investigation, in my opinion death occurred at causes) stated. ° ' Me time, date and place and due to the cause(sl staled. (SI nature and Title) ► % , ISi nature and Title) ► 29 DID TOBACCO USE CONTRIB TE TO DEATH? 30.a HAS ORGAN OR TISSUE DONATION EN CONSIDERED? 30.b WAS CONSENT GRANTED' 1�,y -r.I� ElYES NO J 0 UNKNOWN r/ � YES NO El YES /t.�v1 NO 31 NAME AND ADDRESS C TIFI R (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or P t) / "" Dr John A Wagoner MD 8 0 Al a Grand Island,NE 68803 -ii-a- REGISTRAR ,t[ !r -77TE FILED BY REGISTRAR (Mo.. Day Yr.) `�✓i, NOV 16 2001 i/ v _ i/ v _