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STATE OF NEBRASKA � � �, 2 () `� � � �
<br />� WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VTTAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE I������� �' �"" "U `
<br />STANLEY S. COOPER
<br />�lHY O� 2009 ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH AND
<br />LINCOLN, NEBRASKA HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES p g Z 3 9 2 7
<br />C T C E EAT
<br />7. DECEDENTSNAb1E (Flrat, AAId�Ue, L�t, SuHI:) Z 8D( 3. DATE OF DEATH (Mo.,Day,Yr.)
<br />Eva Faye A Female A ri128, 2009
<br />4, CITY AND STATE OR TERRITORY, OR FOREION COUNTRY OF BQiTH 8a A6E-Lm! Birthdey Bb. UNDER 1 YEAR Bc. UNDER 7 DAY 8. OATE OF BIRTH (Mo„ Day, Yr.)
<br />(rin.) dIOS. DA1B HOUR9 A�IS.
<br />Grand Island, Nebraska 83 August 26, 1945 �
<br />7. BOCULL BECURITY NUMBER 8a. PLI1C8 OF DEATH
<br />5 8-54-3105 NosaRa� � N�eM Q�$:� Nureing HomeILTC � Hosplee Facplly
<br />� 8b. FA4IUTY-NNNE (B �rot Uretitutlon, Bhre atreat m�d ��onbe�) ❑��P�� ❑ DxedeMs Home
<br />Park Place-A Golden Living Center � °OA �
<br />Ba. CITY OR TOWN OF DEATH (include ap Code) Bd. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />� 8a REBNENCE3TAT¢ 8b. COUNTY ec. CITY OR TOWN
<br />;� Nebraska Hall Grand Island
<br />' sd. srrt�r nrto ntuees� ee. arr N0. 9t aP CODB ea. u�s�ne cm umrrs
<br />� 628 N. �roadwell Ave. 68803 � r�s ❑ No
<br />� � 70a MARISAL 9TATU9 AT TIAAE OF DEATH � EAarAed ❑ Never EAarHad 10b. NAME OR 8POU9H (Flrak, Middle, Last, BuHix) N wHe, 8� �den neme.
<br />❑ m�Ba, n�n8e�ea p una�a -❑ oroo�a ❑ u�w�own Lonnie Awtry
<br />m
<br />�� 71. FATHER'SNAMH (Flret, AAiddle, Laet, BuHI:) 12 MOTHER'&NAd1E (Flrel, AAidtlle, fdalden Stuname)
<br />V
<br />p,f Paul Roberts Sr Nona Wilson
<br />m 13. EVER IN U.& ARMED FORCE87 fiWe datea of eervice U Yee. 74e. WFORNWNT•NAd1E 146. RELATIONSHIP TO DECEDENT
<br />1�-
<br />(Yes, No, m Unk) Np Lonnie Awt Husband
<br />78. INETHO� OF DISPOSITION 18a EAABALNIER-SIONATURE 18b. LICENSE NO. 18c. DATE (Ado„ Day, Yr.)
<br />� � °oi " d° " Not Embalmed A ril 29, 2009
<br />�cmnnnae ❑erawnnme��
<br />��� �� 1Bd.CEAAETERY,CREfYIATORYOROTHERLOCATION CITYITOWN $TATE
<br />Central Nebraska CremaUon Service Gibbon Nebreska
<br />17a FUNERAL HOESE W1ME AND AAAILWO A�ORESS (Stroet, City or Town, S�te) 17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See instructions and exam les
<br />7l.PARTLEnMttlro e6alnMare�.Ne�me,inpules,meompRCatimie.Umt�aNycsumtltMdeaN.DONOTaavm�minal�r�nbn¢hnwnWeurau, � APPRO7UEAATEINTERVAL
<br />n+Ph�n�Y urat. or ranWeul�fWdliatlon wlthout showinB tlre atlotopy.00 NOTABBREVINTB. EMer on1Y aro causa on � Ma. Atltl aA�aroi Mas B mewary. �
<br />IAAAAEDIATE CAUSE � o�et bo death
<br />IAAdIEDIATE CAUSE (Flrml � O , ) ,� � r �( /
<br />dieeasa w co�Mitlon resWd� a) n � N �irf/�
<br />In deatl�) 1 �
<br />DUE TO, OR AS A CONSEQUEWCE OF: � o�met to death
<br />8equentletlY Ilst canmdmre. H b) `/ c . / � �1 /�(N`s . C K (w• � ( � � 3
<br />enY. leam� to tl�e ceuee Reted � t l/�/ /� c�.
<br />on Ilne a DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />i
<br />Enter the UNDERLYINO CAUSB a) � r � f ( rj � �S ( � ' �jLL� �S '
<br />(dleease or InJwY �hat Inideted i
<br />the eve�Ks reaWting In deafh) DUE TO, OR A8 A CONBEqUENCE OF: � o�met to death
<br />LAST �
<br />�
<br />�
<br />d) �
<br />1& PART tl. OTHER SIONIFlCANT CONDITIONS�ConrllUOna contributing to the deafh but not reeultlng In Ure umladying cauae glven In PART L 19. WAS MEDICAL FXAMINER
<br />� ORCORONERCONTACTED7
<br />❑ YES � NO
<br />� Z0. IF FEmALE: 21a EAANNER OF DEATH 216. IF TRAN9POFiTAT10N INJURY 21a WA8 AN AUTOP9Y PERFOReAED7
<br />Not pregnent wlthin past yeer ❑ Homidde ❑ OrivaAOpuretor ❑ YES �10
<br />� ❑Prepnant at tlme M death Acelda�U ❑ Petlding Imestl9alton ❑ Pessee9er 27d. WERE AUTOP311 FlNDINt38 AVen eai �
<br />a ,. ❑ NM pregnaM, but prepnaM withln 42 days M death ❑ Sulcide ❑ Coutd �rot be detertNned ❑ Pedestrim� TO C061pLEi'E CAUSE OF DEATH9
<br />.o ❑ Not preg�unt, 6ut pregnent 43 daya to 1 year before death ❑ Othar (BP�KS') ❑ YES �NO
<br />�� �UnWrown It pregnent withln tlre past year
<br />O 21a DATE OF INJURY (biu, DaY. Yr.) 226. TIEAE OF INJURY 2ZC. PLACB OF WJURY-At home. te+m, eL'eeR �aetory. oHlae builmn8� eomtructlon eke. eto. (BP�ffY)
<br />C -
<br />0 2'td. WJURY AT WORK? 22e. DFBCRIBE HOW INJURY OCCURRED
<br />�' ❑ YES ❑ NO
<br />72L LOCATION OF INJURY • STREET d NUb78ER, APT. NO. CIiYITOWN STATE 21P CODE
<br />23a. DATE OF DEATH (Mo„ Day, Yr.) 14a. DATE 81(iNED (mo., Gay, Yr.) 24b. TUNE OF DEATH
<br />�'� April 28 2009 . m
<br />�� 23b. DATE SIONED (fdo., Day, Yr.) �. TUAE OF DFATH p7 y O 24c. PRONOUNCED DEAD (Mo., Day, Yr.) Z4d. TI�E�PRONWNCED DEAD
<br />in Z
<br />Edo �� � 2:00 P.m E ya o m
<br />$� 23d. To the beat ot my Imowtedge, death oceurted at the 8me. dete a�M ptsae $�� 24e. On the hasis ot e:artdnatlon end/or investlpadon, M my opWon death oeeimed
<br />� end due W cauae(s) (SI d Tftle) p �� � et fhe 8me, dete and place and due lo the eauea(s� s�. (Slgnaturs m�d ntle)
<br />I- /� T. Ct
<br />(\. IV�j t� `o
<br />28. D1D TOBACCO USE CONTRIBUTE TO THE DEATHT ZBa. HAS OROAN OR TI88U8 DONATION BEEN CONSID8RED7 28b. WAS CONSENT ORANTED9
<br />❑ YES , �#IG--� PROBABLY ❑ UNKNOWN ❑ YES Not Appl(cabte H 28a le NO ❑ YE8 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICUW OR COUNTY A770RNB1� (Type or Print)
<br />David Colan, M.D., 729 N. Custer Ave.,, Grand Island, Nebraska 68803
<br />28e. REaISTRAR'S SIONATURE 28b. DATE FlLED BY RECi18TRAR (AAo., DaY� Yr.)
<br />�p � ,��� � MAY 4 2009 -
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