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<br />STATE OF NEBRASKA F"� � T
<br />WI�EN THIS COPY CARRIES THE RA15ED SEAL OF THE IUEBRASKA DEPARTMENT OF HEAL�(-F�ND N M��1t � �l�VIC�S, I'f CERTIFIES
<br />THLF BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE IVEBR�KA�4a�'P�IYtTI�/i1T �IF�-IEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS' OFFICE, WHICH IS THE LEGAL DEPOSITORY FOI�'VT�A�.. R�F��I�DS `� , O
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<br />DATE Of ISSUANCE µ r ,' � � ,,
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<br />� �W�. � � �Id6� � STAI���1��G s`�T�A'� �
<br />s � . ' -�fR DF H�A�.T� /AN� �''' '
<br />LIN�OLN; NEBRASKA �, O 3., � O O� O e7 ,�, ' fd'�JM�11.S -�R�' VI�S'-` �,�,. r i,'
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<br />STATfl OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES -`� ,�,�„4,< �-
<br />CERTIFICATE OF DEATH �, .'`; 1 O Z 5 9� O
<br />1. pECEDENTS•NAME (Flret, MWdle, Laet, SatPoc) 2 6E%' �, 3. DATE OF.OEATH (Ma, Dey, Yr.)
<br />Ma�e Jul 14 201 •
<br />4. CITY AND STATE OH TERHITOFiY, OR FOREICiN COUNTRY OF BIRTH Be. At3E-Lest Birthday 6b. UNDER 1 YEAR 60. UNCER 1 DAY 8. DATE OF BIHTH (ma, Day, Yr.)
<br />(yre,) MOS. OAY9 HWRS MIN3.
<br />�oniphar�,l!Nlebra�ka 91 � A ril 23 1919
<br />' 7. �bCIAL SECUHITY NUMBER � ' Ba PLACE OF DEATH � � � -
<br />505 -18- �: ❑�em 9IdEfl: ❑ Nureing Home/LTC O Hospice Facllity
<br />8b. pACILRY NAME pf not InsUmtlon, give str�t end munbe� O�p� ❑ Decedem'e Home
<br />T e Landi'n t Wi l i r �� i%ome�csa�n� Acct � i�in�
<br />80., fIY OR TOWN 0� DfJ1TH (Inolude Zip Code) Bd. COUNTY OF D6A7H
<br />�incoln 68516 l.anc�ster
<br />8e.'HESIDENCE-9TATE . . � Bb. COUNTY 9a CITY OR TOWN -
<br />�
<br />8d.',�4TREET AND NUMBER' � . . Be. APT. NO
<br />500 Faulkner Drive
<br />10�. MARRAL 6TATU9 AT TIME OF DEATH . h9artietl O Nerer Merried 10b. NAME OF BPOUSE (Flret, Middle, Lest, SWt6c) It wile,
<br />O Mflm�d, n�rt se�a 0 vnd�ed ❑ D(vorced O Unknown
<br />, Maril n Knox
<br />11:,pATHEW&NAME (Flral. Middle, Laet, 9uffix) 12.MOTHER'SNAAIE (FUat,
<br />Frank Llo d ' Adams
<br />13. EVER IN U.8. ARMED FQACE9? (iive detea of serv�6 N yea. 14a. INFORMANT-NAME
<br />rr��ol�a Yes 10-20-41/10-9-45 Marj7 n Ad
<br />15.�METHOD tlF DISPOSI770N 1Be. EMBALIdER-81�NATUqE �
<br />I .O Buriel 0 �onelWn .� Gti.a-
<br />I CX Cremaqon 0 Entombment ��• CEME'I'ERY, CREMATORY OR OTHER LOCATION
<br />', 0 Removal O Otner (sP�KY) � . � �, '. �
<br />Lincoln Cremation Serv
<br />17� FUNERAL HOME NAME AND MAILINO ADDRESS (SVee2, Ciry or Torq State)
<br />Roner and Sons. Inc.. 4300 '0' Street. L
<br />Bg.IN91DE CITY LIMITB
<br />f�] res o No - .
<br />Meiden Sumeme)
<br />iHIP 70 DECEDENT .
<br />18c. DATE (Ma. Day, Yc ) -
<br />July 17, 2010
<br />STATE
<br />Nebraska
<br />17b.Ilp Code
<br />18: � PART I. �rrter the chain of eventa-dlseases,�inJurlea, or camplitretlons-that tliredUy mused Ihe death. DO NOT eMer tarminal evems euah; as oertl�ac atteat, � nrrnwv�.w� ���. � G,..,�.
<br />I
<br />��� re8piretmy artest, m ventriCUler flit�lladol� without ehawl� ihe etlulogy. b0 NOT A9BREVIATE. Enter only one cauee on e Wre. Add eddlUanal Wrea H necaesery. � �
<br />' � IMMEDIATE CAUSE � � I anset to death
<br />I
<br />��Q�� I
<br />imqtmare cauae (� �e� �►O 2A�'t�Q�/ A✓�ST ,,,� m u�azn
<br />�ge w eondidon t�Wffitg DUE T0, OR A9 A CONSE�UENCE OF: � �
<br />In tleath) . _ � I I
<br />tb' I
<br />S�°endeny Ilst °°�dfllQ�' DIIE 0, OR AS A CONSE�UENCE OF: � onset to death
<br />HenY� l�din9lo the cauee � � I
<br />�Me �UNDEiiLYWfl (o) /� �/.�J (��J G� I I�GCY/J� L ��./aI� � �
<br />CAUSE (maeaae oi �n�ury U�at � DUE 0, OR A CONSE�UEN 0 � ' � ', � � onset to death
<br />INtleted Ne eve�rte tesulNrt9, ' i
<br />IndeEUt}LABT �; . � � � I
<br />I
<br />18. PART II.OTHER 816NIFICANT CONDITIbNS-Camlillone mntribuUng to the death but not tesulUng In the wderlying cau� ghren In PART I. 18. WA3 MmICAL OWMINER
<br />/ / OR CORONEfl CONTACTE07
<br />^ , r� ! G I �/1 dL �i• ( t//"� �i0 � � 7 �i fd f�f � res ❑ No
<br />20;�IF FEMALE: �� � �Pta. MANNER F DEAYH ' 216JFTRAN3PORTATION INJURY �' 270. WA8 AN AUTOPSY PERFORMED?
<br />'�'Nalurei ❑ Homicide ❑ OfiredOperetor
<br />O� Pbt PreB�em wtthin' Pe� Y� ❑ YE8 �I NO
<br />O.', Pregnenc et ume of aeath ❑ q��g�0 p�p„e ����ggryo„ ❑ P��9er
<br />❑ Not pr9gnanl, hut pregnant within 42 days of deatii � P ��� 21d. WERE AUTOPSY FlNDIN�S AVAILABLETO
<br />O 3uidde 0 CouW datermhred ❑ Othet (3peciyl
<br />Q', Not pregnent but pregnent 43 daye to i yeer 6efore dea�h COMPLETE CAUSE OF DEATH?
<br />� Unknnwn H prepnent within the past yeer ❑ YE8 �NO
<br />22�. DA7E OF INJURY (Mo.. Dey, YrJ 22b.TiMS OF WJURY 220. PLACE OF INJURKAt homa, tarm, etreeR �adory, affi¢e buildln9. conaWCUn^ siie, etc. (Spedfy) �_
<br />- -- - m - - - ._
<br />_ _- �---
<br />22d. IN.IURY AT WORK7 22e. DESCRIBE HOW INJURY OCCURRED �
<br />-+ QYEB'�NO . I , . . .
<br />ii' i
<br />:ii 22�. LOCA170N OF INJUqY - STREET &�NUMBER. AF+T. N0. CiTY(fOWN � STATE ZIP CADE
<br />-,.��
<br />��` � � 23a. DA7E OF DEATH (Mo., Day, Yr.j � 24a. DATE SI�NEU (Mo., Day, Yr,) 24b. TIME OF DEATH
<br />�'� �'�� J 14 1 .��� m
<br />�f �E �� 236.OAT SI�PiED (Mo., Day,�YrJ 23e.TIME OF DLATH �� �� �' 24a. PRONOUNCEU DEAD (Mo., Day,Yr.) �24d.TIME PHONOUNCED DEAD
<br />IF Ei7� �►711J. � �:7 �'�2��0� . , � . � m m 4J. . �� n'1
<br />a
<br />,; f�- H . 23d. To ihe bea� 01 my knmvledge, deafh occurted et Ihe tinte, dele snd p1aCe ���� 4e.On tha beais of examinafion andfor Imeatigation, in my opinbn death axurred at
<br />_��, ;, ,$ ��� end due ro ihe causa(s) s . g and TIUe )♦ � ,� Q� t�m tlme, dffie and plaoe and du8 to ihe cause(s) etetad. (Stgnature and TIUe )♦
<br />_ ���� �.ww / J o¢�
<br />4. ! �'�� ~ c� g
<br />{ 2�� OID T08ACC0 USE CONTRIBUTE TO THE DEATH4 28a. HAS OROAN OR TISSUE DONATION BEEN CONSIDERED7 28ti. WAS CONSENT 6RANTED?
<br />�� ' O YE3 ❑ NO ❑ PROBABLY NKNOWN ❑ YE8 NO Not A Ilcehle (f 26aie no ❑ YES ❑ NO
<br />�" 27. NAME, TITLE AND ADDRES9� OF CERI'IFIER (PHYBICIAN, PHYBICIAN !w.^SISTANI; CARONER'B PHYSICUIN OH COUNYY ATfORNE1� (7ype or Print� �
<br />�;` ;% •Michael Paoe, NID 3901 Pine Iake Rd, Suite 220 I,incolCl, NE 68516
<br />28a HEGISTRAR' NRE w� 28b. DATE FILEO BY RE�I9TRAR (PAo., Day, Yr.)
<br />� � JUL 16 2010
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<br />HHS-61 Rev 7/09 (55061)
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<br />aen rmme.
<br />�. M1rtiddle,
<br />LICENSE N0. '.
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<br />CI'IYITOWN I
<br />Lincol
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