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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEA� OF THE NEBRASKA DEPARTMENT OF HEALTH,�Af41D HUI�I'Al1f $ERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE IVEBRA�f�A Q�'Pbl�t�'JN�MF OF+' MEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR t�TT',aL�RECOJ�'D5' � i
<br />� �•�, (,�, a "� ,'�
<br />DATE OF ISSUANCE }
<br />��.����� ' 1��� ° °
<br />11 /22/2011 STA�1lLEY S.-�OQPER ` a f;'
<br />2 p 12 014 � S A55?$TAN7'_�7'.4 �E�ISTRAR
<br />1� E P� T M E N T O F H E A L T H A N[) , ��
<br />LiNCOLN, NEBRASKA � �. H�MII� ��f��/TGES`� � ,, �� , °" �
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVIC�E.S���� ���� �`-�{ }!., ��~� . �" ; Y 1 �1 OSSZB
<br />/�C�TIGIf+ATC AG �1C ATY . � � ? " � * - � - ' -
<br />v�■�� u.vr�■ � v■ rrr�.. _ ., � . .
<br />1. DECEDENTS-NAME (Fhst, Middla, lset, Suftbc) 2. SIX ' "t. ;.; � 3:-DATE OF DEATH (Mo., Day, Yr.)
<br />Marcellene Marle Young Female ,' `Novemtier 17, 2011
<br />4. CIl'Y AND STATE OR TERRITORY, OR FOREION COUNTRY OF BIRTH Sa. AGE • Last BlRhday b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(�'B•1 MOS. DAYS HOURS MINS.
<br />Holstein, Nebraska 79 August 28, 1932
<br />7. SOCULL SECURITY NUMBER 8a. PLACE OF DEATH
<br />505-36-2755 OSPIT ❑ Inpatlent OTHER � Nursing Home/LTC � Hospice Facility
<br />8b. FACILITY-NAME pf not Institutlon, give streat ami number) ��p�p��e� � Decederrt's Home
<br />K
<br />� 'Wedgewood Care Center ❑ DOA ❑ Other�SpecHy)
<br />� 8c. CITY OR TOWN OF DEATH Qnclude Zip Code) 8d. COU��TY OF L'EATH
<br />c Grand Island 68803 Hall
<br />� ea. RESIDENCESTATE 8b. COUNTY 9c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />� 8d. STREET AND NUMBER 8e. APT. NO. 8L ZIP CODE 8g. INSIDE CITY UMITS
<br />�` 2531 W. Phoenix 68803 � v�s ❑ No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH � Married ❑ Never Married 10b. NAME OF SPOUSE (Firat, Mlddle, Last, SuRhc) IT wHe, 8We rt�iden reme
<br />� p nna�aa, n�n ea��tea ❑ wnao,Nea ❑ nn.o.�ea ❑ u��o� Donald Young
<br />d
<br />� 11: FATHER'S�NAME (FUat, Mlddle, Laet, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Sumame)
<br />m John Halbmaier Anna Catherine Faber
<br />� 73, EVER IN U.S. ARMED FORCES7 Give datea of servlce N Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />� (rea, No, or unk.) No Donald Young Husband
<br />,$ 18. METHOD OF DISPOSI170N 18a. EMBALMERSIONATURE 18b. LICENSE NO. 18e. DATE (Mo., Day, Yr.)
<br />F � Burlal ❑ Doretlon
<br />Matthew T. Myers 1411 November 23, 2011
<br />❑ Crematlon Q EMombmeM 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (SpecHy)
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND NU4ILING ADDRESS (Street, Cily or Town, Shate) 17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUS OF D T See instructions and exam les
<br />1&�PART I. Enter the ehaln ot eva�ne..d�aeasea, ln)ur�es, or comp�icadons4hat dlrecGy caused the death. DO NO7 eMe� terMnal eveMe such ae carAlac arreae, p APPR070MATE INTERVAL
<br />respUStory artest, or veMricular flbrUlatlon wtthout ehmMng Ure adotogy. DO NOT ABBREVUITE. Frrter only ane cause on e 16re. Add atltlitlonal U� it irecessary.
<br />IMMEDIATE CAUSE: ; onset to death
<br />ma�oa� cnuse �� al Carcinoma Of Lung ; 1 Year
<br />tllsease or canditlon reauldng �
<br />�" �'� DUE TO, OR AS A CONSEQUENCE OF: ; onsat to death
<br />saa�mm�anr ass comUUona u b)
<br />a�ry, leading to the cause Iletetl
<br />on Ihre a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />Ehter the UNDERLYINO CAUSE �) �
<br />(diseaae or iryury Nmt Inidated
<br />��"�Hf�"e �^ �'� DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />war d) �
<br />18. PART 11. OTHER SIGNIFlCANT CONDITIONS�CondlUons coMrlbuting to the death but not resulting In the uMleriying cauae gtven in PART I. 19. WAS MEDICAL EXAMINER
<br />Chronfc ObsVuctive Pulmonary Disease OR CORONER CONTACTED7
<br />� ❑ YES � NO
<br />� 0: IF FEMALE: 21a. MANNER OF OEATH 21b. IF TRANSPORTATION INJUR 21e. WAS AN AUTOPSY PERFORMED?
<br />� � Nat pregna�rtwithln pastyeaz � Netural � Homldde � DrWeAOpe�aWf ��s � NO
<br />v [] are � u� �r a� � a�iaaM � PendlnB InvestlBadon ❑ Paseenger
<br />T � Not pregnem, but pregnam wRh�n 42 daye oi death SmWtle CoWd not be detemtlireu � P��O 21d. WERE AUTOPSY FlNDINGS AVAILABL
<br />a ' � ? � nta nra¢�ns, nut pre¢nane � aaye m t year berore aeath � � � � p�� �gpe� TO COMPLETE CAUSE OF DEATH?
<br />� �] unknown n Weenant wttMn the n� rear ❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, atreet, factory, offlce buliding, cor�structlon e(te, etc. (Speetfyr)
<br />$
<br />.� ZZd. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />�"' � YES � NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYfTOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />.� November 17, 2011 .s � �
<br />� � 23b. DATE SIGNED (Allo., Day, Yr.) 23c. TIME OF DEATH �' �� 24e. PRONOUNCED DEAD (Mo., Day. Yr.) 24d. TIME PRONOUNCED DEAD
<br />� Z November 17, 2011 08:40 AM � a a�
<br />$ O . To tlre beet of my knowledge. death oecurred et the tlme. date and plaea $ O
<br />44e. On the basis af exaMnaUon antl/m ImreatlBadon, in my opinlon death occurted at
<br />�� and Aue to the cause(s) efeDed. (Signature and TMie) � (he tlme, date and place and due to the eauee�e) atated. (Signature entl Tttle)
<br />~ Wllliam Landis, MD ~ g s
<br />2S. D1D TOBACCO USE CONTRIBUTE TO THE DEATH4 28a. HAS QRGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED4
<br />� YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applleable N 26a is NO ❑ YES ❑ NO
<br />27. E, TI D ADDRE F CERTIFlER PHY IC , H IC T, R R R O ype or Pnrrt)
<br />WilUam Landis, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIaNATURE �' ��+- 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />Qp�...
<br />Novamber 18, 2011
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