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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEgL�'H AND-HUM�1 SERVICES, IT CERTIFIES
<br />� THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASI(A i)�pARTN1ENT OFNE4LTH AND
<br />HUMAN 5ERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY F�R Y�TAt<12EC�RDS "{
<br />DATE OF ISSUANCE _ -`�� a L��! ,
<br />�����d��
<br />01/06/2012 staN�s: Coow�� ,,�
<br />2 012 0 0 5 6� AS$��, �T�.�FR������� ��: ;
<br />DP�'A��IFIVT_OFJ(EAL�fYA'i�Fp �
<br />LINCOLN, NEBRASKA HUM�U'S -RV ES �
<br />. . .. I �. � ! ,��..
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERV6GES ����' �� ��. � l �_ .. 11 04404
<br />GERTIFIGATE OF DEATIi ':�` �. '� '` '� - -
<br />,
<br />1. pECEDENTS•NAME (Fhst, dliddle, Last, Suffbt� 2. Sqf t ;° i 3 p (Mo., Oay, Yr.)
<br />Arthur Duane Davis Male �� '� ���scem4,er2�2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last Birthday b. UNDER 1 YEAR Sc: UNDER 1 Y,�`%8. DA'�E BIRTH (MO., Day, Yr.) ,
<br />(�'�•I MOS. DAYS HOURS MIN9.
<br />Shelby, Nebraska 80 December 16, 1931
<br />7. SOCIAL SECURITY NUMBER 88. PLACE OF DEATH
<br />553 os H PITAL 0 n�aneM OTHER ❑ Nursing Home/LTC � Hosplee Facllily
<br />8b. FACILITY•NAN� (if rrot Inatitutlon, give street and numbeh ��/p�petierR ❑ Decederrt's Home
<br />K
<br />� Saint Francis Medical Center ❑ noa ❑ aner �speeiry)
<br />� 8e. CITY OR TOWN OF DEATH p�lude Zlp Code) 8d. COUNTY OF UEATH
<br />o Grand Island 68803 Hall
<br />� ea. RESIDENCE-STATE 9b. COUNTY 9a CITY OR TOWN
<br />Z Nebraska Hail Grand Island
<br />� 9d. &TREE� AND NUMBER 8e. APT. N0. 8f. ZIP CODE 9p. INSIDE CITY LIMITS
<br />T 3004 Westside Street 68803 � res ❑ No
<br />' 10a. MARITAL STATUS AT TIME OF DEATH Marrled
<br />.� � ❑ Never Mar►led 10b. NAME OF SPOUSE (Firet, Middte, Last, SuHix) If wHe, B�e maiden name
<br />� ❑ nnarriea, n�n 88paraeaa p v�naowea ❑ on�oreea ❑ unk�ow� Carolyn Condell
<br />� 11. FATHER'S-NAME (Ffrst, Npddle, Last, Suftiz) 72. MOTHER'S-NAME (Flrst, Middle, Malden Surname)
<br />Austin Eugene Davis Susan Belle McMillen
<br />°' 13: EVER IN US. ARMED FORCES? Gtve datea of service H Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />S
<br />$ n�, No, or une.) No Carol Davis Wife
<br />,$ 15. METHOD OF DISPOSII'ION 16a. EMBALMERSIGNATURE 18b. LICENSE NO. 18e. DATE (Mo., Day, Yr.)
<br />F � Burial ❑ Donatlon
<br />William D. Greenway 0913 December 30, 2011
<br />� CremaUon ❑ Eirtombmerrt 78d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Remorai ❑ Other (Specffy) Rose HIII Cemetery Patmer Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, C or Town, State) 17b. Zip Code
<br />Greenway Funeral Home, 802 Templin, Palmer, Nebraska 68864
<br />CAUSE OF DEA See instructions and exam les
<br />18. PART 1. EMer Ure gffiIn ui eve�rte-�diseasas, InJurlee, or compllmUo�-that directly causetl the death. DO NOT e�rter tertNnal eveMe �ch as cardlac arteat, ; APPROXIMATE INTERVAL
<br />reeplratory artest, or veMrlwiar flbrAiadon wMOUt ehowing tha etlotogy DO NOT ABBREVIATE. Frrter oNy one wuee on a Me. Add adUttlonal Mae H�ry.
<br />IMMEDIATE CAUSE: ; areat to death
<br />IMMEDIATE CAUSE (Fl�ml a) Pneumonia ; One Week
<br />tllsease or conditlon resuidng
<br />In ueatn� DUE TO, OR AS A CONSEQUENCE OF: : o�et to death
<br />SequeMially qet co�Mklon& H b)
<br />a�ry, leading to the cauae Ilsted
<br />on ime a. DUE TO, OR AS A CONSEQUENCE OF: ' � o�et to death
<br />EMer the UNDERLYINO CAUSE ��
<br />(dlsease or InJury that InlGated �
<br />Ure 8"e"m ras"m"a i" deatt'� DUE TO, OR /6S A CONSEQUENCE OF: � o�et to death
<br />'asT d)
<br />18. PART II.OTHER SIGNIFlCANT CONDITIONS-Condttions wntribuqng to the death but not resulUng in the underlying cause given in PART I. 19. WAS MEDICAL EXAANNER
<br />GBSVointestin8l Bleed OR CORONER CONTACTED4
<br />� ❑ YES � NO
<br />W 0. IF FENW.E: T7a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21e. WAS AN AUTOPSY PERFORMED?
<br />W
<br />� � Not P�eB��rtwithin pestY� � Neturel � Homldde � OriverfOPeretor � YES � NO
<br />v ❑ P�e"a"� � n"� a°�n p awa�rc � Pendin9lnvestl9atlon 0�"��
<br />� � Not pregnant, but pregna�rt wlthln 42 daye oi deatb � Pedestrian 21 d. WERE AUTOPSY FINDMGS AYAILABLE
<br />Butclde CoWd not be determined
<br />❑ TO COMPLETE CAUSE OF DEATH7
<br />� NOS PreBnaM. but P�eBnant A9 d8ya t0 7 yeaz beTore tleath � Other ($P�Y) ❑ ❑
<br />� ❑ Unlmown H preg�m�rt wmm the �mat year YES NO
<br />°' 22a. DATE OF INJURY (Mo, Day, Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURY•At home, tarm, atreet, factory, oftice buliding, eormtruetlon ake, etc. (Speeify)
<br />E
<br />�
<br />.� 22d. INJURY AT WORK7 22e. DESCRIBE HOW INJURY OCCURRED
<br />Ip
<br />❑ YES ❑ NO
<br />72F. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />2Sa. DATE OF DEATH (Mo, Day, Yr.) � 24a. DATE S(GNED (Mo, Day, Yr.) 24b. TIME OF DEATH
<br />B � December 27, 2011 ,� �
<br />� Y 23b. DATE SIONED (Mo., Day, Yr.) 23c. TIME OF DEATH � y k� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />Z December 30, 2011 01:50 PM �� 4�
<br />$�� � 3d. To the beat M mY knowleAge. death occurted et the tl�re. date and Place $ R� O
<br />a�M Aue to the cauee(s) ahated. (Sipnature end T1Ue 8 Q Z4% On the besie ot esaminatlon enNOr inveatipatlon, in my oplNOn death oaurted at
<br />�� 1 $ the tlme, date and place and due M the cause(e) afated. (Slpnature and TIUe)
<br />~ Donald Wirth, MD ~ g o
<br />2S. DID TOBACCO USE CONTWBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED7 28b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNONlN ❑ YES � NO NotAppllcable IT28a is NO ❑ YES ❑ NO
<br />2. E, D AD R O CERTIF ER P 1 Y I 1 TAN , OR ER 1 IAN O O ORN (Type w Print)
<br />Donald Wirth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE �- 28b. DATE FlLED BY REGISTRAR (Mo., �y, Yr.)
<br />January 6, 2012
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