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� STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF .HEALTt�;�QlY��,HtI,P?A, N,SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINA! RECORD ON FILE WITH THE NEBRf��'l�4 F.� P � A�`TiM,�� �.,�IEA�.TH AND
<br />HUMAN SERVICES, � VTTAL RECORDS` OFFICE,. WHICH IS THE LEGAL DEPOSITORY'�'Q'J7'�l17'�''�EC�O�d�. ,��`'+' 1 r ''
<br />�~ � • ��;.,• ''�` .,��"
<br />qATE Ofr ISSfIANCE r ; � ,�' _ � , R �"' _ �,
<br />�12/14/2011 '' �� ��,��` Ss. �F.,� ��' ! �
<br />�� � ��� �01�0026� , `� �����.���� �
<br />LiNEOLN, NEBRASKA .:^ ��'�AN.�!°Ritl�'�,rs , , �;; �a ���
<br />STATE OF NEBRASKA- DEPARTdIENT OF HEALTH AND HUMA�f�$E�/ICE ".`' �� �,� �r.,�", �� O 01801
<br />CERTIFICATE OF DEATH .;�: �,'!�', �#�'� ���°��``'° • u, � '��° .
<br />1. DE¢EDEN7'&NAME (Firet, NUddle� Lesq Suftizl ' �, 2. �C �,Ir��,,�y .S. DATE bF DEATH (Mo Day� Yr.)
<br />Je Lee Mlller 6Aal� �;�, . A,ugUst 10, 2009
<br />4.� CITY AND 3TATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Laet Birthday b. UNDER 7 YEAR 5c. UNDER 1 DAY'` '8.`DATL, QF BIRTH (Mo., Day, Yr.)
<br />(Yre.1 MO3. DAYS HOURS MINB. � '
<br />Grand Island, Nebraska 58 September 28,1950
<br />7. SOCIAL SECURITY NUMBBR 8a. PLACE OF DEATH '
<br />505-70-9�J65 ' �❑ InpaUent ' O, THER ❑ Nursing HomelLTC � HosPice FacilHy
<br />8q. FACIUTY•NAME pf not I�reUtuUon, ghe atr�t ami m�mberj ��yp��� [] DecedenYa Home
<br />�
<br />� Saint Francis Medical Center ❑ oon ❑ other tspeciry)
<br />�
<br />. CITY OR TOWN OF DEATH Qnclude Zlp Cale) Bd. COUNTY OF DEATH
<br />c `Grand Island 68803 Hall
<br />R�SIDENCE-STATE 9b. UNTY 8c. CITY OR TOWN
<br />� ' Nebraska Hall Grand Island
<br />LL 8�1. STREET AND NUdIBER . APT. NO. 8(. ZIP CODE 9g. INSIDE CITY LfIWT3
<br />� � 108 W. 14th St. 68801 � ves ❑ No
<br />II 10a. NIARITAL STATUS AT TIME OF DEATH Q Married � Ne�rer Martled 10b. NAME OF SPOUSE (Flret, Middle, Last, Suftbc) if wife, gNe ��den �me
<br />�' p nneM.a, n�s se��eea ❑ vinaowea ❑ o�oreea p unk�own
<br />� 11. PATHER S•NAME (First, Middie, Last, SuHix) � 72. MOTHER'S�NAME (First, Middle, M1�idan Sumame)
<br />Alvin Peter MUler Arlene Helen Bremer
<br />°" 1. EYER IN U.S. ARMED FORCE9? Oive dates oT ServlCe H Yes. 14a. INFORMANT•NAME 74b. RELATIONSHIP TO DECEDENT
<br />E ,
<br />$ �res, r►o, or unic.� No � Alvin Peter M111er Father
<br />,$ , 1. METHOD OF DISPOSITION 788. EMBALRAERSIGNqTURE 18b. UCENSE NO. 7Bc. DATE (Mo., Day, Yr.)
<br />� � Burial ❑ Do�mUon '
<br />' Daniel' D Naranjo 1071 August 17, 2009
<br />Q CremaUon ❑ ErRombment
<br />I 76d. CEME7ERY, CREMpTOSY OR �THER LOCATION , CITY /TOWN STATE
<br />� Removal ❑ OUrer (SpecHy) W�Uawn Memorial Park Cemetery Grand Istand Nebraska
<br />1 a. FUNERAL HOME NAMB AND MAILINO ADDRESS (Street, Ctty or Town, State) 17b. 2Ip Code
<br />AII Faiths Funeral Home, 29'29 S. Loaust Street, Grand Island, Nebraska , 68801
<br />18. PART L Fr�tertlre chafn of eveMS-dlsaa�, InJurles, ot compUCatio�tl�at GUectly caused the deat6. DO NOT eMer
<br />. reapiretory artesl, or ventricutar flbriUaUon without sAowing the eNOtogy. DO NOT ABBREVIATB. E�rtet onry one a
<br />IMMEDWTE CAUSE:
<br />I uxe�ou►Te c,wse � e) Cardiorespiratory Arr�st
<br />�� m canamon reauttlng
<br />"""' h � D{!E TO, OR AS A CONSEQU�NCE OF:
<br />U N
<br />�ty u� ��aw„�,, u b) Inferior Wali Myoc�rdial Infarc8on
<br />�,, leadlnp to the cauBe 118[�
<br />",� a , DUE TO, OR AS A CONSEQUENCE OF:
<br />� rUre uNoER4Ymio CAUSE C � � . . . . �
<br />or InJury Shat InlNated
<br />�e"� �'��^a �" �) DUE TO, OR AS A CONSEQUENCE OF:
<br />1,.A8T , I d) . , ,
<br />!s auch ae nrutac eeeat. : APPROXIAAATE INTERVAL
<br />Add etldidOnel tUtes U �+Y. �
<br />i
<br />= onset to death
<br />3 One Hour
<br />-
<br />1. PART II. QTHER SIGNIFlCANT CONDITfONB�Condido� coiitributi� to the death but rrot reaulHng In the umletlying cauae givan In PART I. !8. MED
<br />OR CORONER CONTACTED7
<br />� ❑ YES � NO
<br />W Zq.IF FENWLE: R1a. NWNNER QF DEATN 21b. IF TRANSPORTATION INJU 21c. WAS AN AUTOPSY PERFORMED4
<br />� � Not P��rtwlthln NeatYea► _ � � NaWrat � HomlWde � DrivedPPerator � . � YES � NO
<br />� . k] Pre9� at tirtre of deafh .- .� Acdaem � Pemlitre Investlpatlon ❑�"�� .
<br />Not pregna�rt, but pregnant withln 42 aeye oi deatL Pedestrian 27d. WERE AUTOPSY FlNDINGS AVAILA
<br />'� ;Q Not P�e6�aM. but we¢�t 4s deye to 1 year betore dea� � 0 8u1 �� ❑ C�id �rot 6e dete�mhretl Q Oelrer lBPedbl TO COMPLETE CAUSB OF DEATH?
<br />� Q UnimownHV��wk6lnthepsMYear ❑ YES ❑ NO
<br />E 2�ta. DATE OF INJURY (Mo„ Day, Yr.) 92b. TIME OF INJURY 2Ze. PLACE OP INJURY-At home, farm, etreet, tactory, ofttee bulldi�, co�retrueUon site, ete. (Specify)
<br />$
<br />� 2Rd. INJURY AT WORK1 22e. DESCRIBE HOW INJURY OCCURRED
<br />1�-
<br />Q YES ❑ NO
<br />�f. LOCATION OF INJURY • STREEl' 8 NUMBER, APT.�10. CITYROWN
<br />23a.. DATE OF DEATH (Mo.. DaYi �N - --- - `_- _
<br />__ �. __ _ I
<br />� �� 23b. DATE SIGNED (Ma., 08y, Yr.) 29c. TIME OF DEATH
<br />� � � ro ure a nn Wrowteaae. aeatn oa�awa ffi ure ame. dale mro-Waee
<br />�� ' aod due to the cause(e) atated. (Signature aMl TtUe)
<br />� ,
<br />❑ YES ❑ NO ' [] PROBABLY � UNIWOWN
<br />TIT F
<br />Jon Hendrick§, Hall Deputy County Attomey
<br />I
<br />STATE
<br />o�et to death
<br />or�set to death
<br />One Hour
<br />ZIP CODE
<br />- 24a. DATE StGNED (Mo, Day, Yr.) 24b. TIME OF DRJITH
<br />� � � August72, 2009 06:00 AM
<br />� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) Z4d. TIME PRONOUNCED DEAI
<br />�< o Au usti 10, 2009 06:07 AM
<br />8� 24e. On Ure beds oTexamineHOn anNOr Ipveedgatlon, In my opinWn deatU oewrrad et
<br />e the dme. date and plaze and due W the aause(e) atated. (3lonarire and Title)
<br />'' g� Jon Hendricks, Hall Deputy County Attomey
<br />�] YES � NO
<br />239 S. Locust, P.O. �Box 367,
<br />rv �
<br />�
<br />i
<br />Island, Nebraska,
<br />za
<br />IT 28a 18 NO ❑ YES ❑ NO
<br />, bATE FlLED BY REGI9TRAR (Mo, Day, Yr.)
<br />August 18, 2009
<br />
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