|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HE�
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR L
<br />I
<br />DATE OF ISSUANCE
<br />02/24/2012 2 012 0 2����
<br />,�.:. � .�, �: ;�
<br />TH �IND �-lU,MAN �ERVICES, IT CERTIFIES
<br />KA D�-F'�9fitME�MF OF'I-�' FALTH AND
<br />TAL' RE��1lt�DS � ' d
<br />� � � , �f r
<br />4 � 6 • �
<br />'Y"S. ��OPEI��� � t ,,, ,
<br />.4MT �ST.4'T� R`EG�S_i"RAR
<br />''!'�IENT;OF HEALTH AND `-
<br />LINCOLN, NEBRASKA HUMAN 5ER4�CES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN 3ERVICES ""' ' `� � 2 OOSS'I
<br />CERTIFICATE OF DEATH
<br />1, pECEDENTS-NAME (Flrst, Middle, Last, SuHbc) 2. SIX 3. DATE OF DEATH (Mo, Day, Yr.)
<br />Eldon Harold Howard Mate February 13, 2012
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last BlRhday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(YB•) MOS. DAYS HOURS MIN3.
<br />Loup County, Nebraska 78 July 18, 1935
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />505 OSPIT jL ❑ �npatlent OTHER ❑ Nursing HomeILTC � Hosplce Faclllly
<br />8b. FACILITY•NAME pf aat Irretltutlon, give street arrci rtumber) � ER/OutpatleM ❑ DeeedenPs Home
<br />�
<br />� Saint Francis Medical Center ❑ oon ❑ otner �speciry)
<br />t�
<br />� Bc: CITY OR TOWN OF DEATH pnclude Zip Code) 8d. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 8a, RESIDENCESTATE 8b. COUNTY 9e. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />7 8d. STREET AND NUMBER S8. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY UMITS
<br />a 4059 W Schimmer D�ive 68803 � ves ❑ No
<br />' 10a. MARRAL STATUS AT TIME OF DEATH � Marrled ❑ Never Martled 10b. NAME OF SPOUSE (Flrsf, Mlddle, Lest, Sufflx) If wHe, gfve rt�lden rmme
<br />v
<br />� ❑ Msrried, but eeperated ❑ wiaow0a ❑ on�o�aa ❑ u��ow� Margaret Gruber
<br />� 11. FATHER'S-NAME (Firaf, dUddle, Last, SuHtu) 72. MOTHER'3-NAME (Flret, Middle, Malden Sumame)
<br />m Jasper Howard Agnes Kamery
<br />E 13. EVER IN U.S. ARMED FORCE9? GNe datea oi servlce if Y�. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ �res, No, or unk.) Yes 06/04/195&06/03/1960 Margaret Howard Wife
<br />,� 18. METMOD OF DISPOSITION 18a. EMBALMERSIONATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />� � Burlal ❑ Doretlon
<br />Matthew T. Myers 1411 February 17, 2012
<br />❑ Crematlon ❑ E�rtombmeM �g�. CEMETERY. CREMA70RY OR OTHER LOCATION CIIY / TOWN STATE
<br />❑ Remo,rai ❑ Other (Specify) Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, CHy or Town, State) 17b. Zlp Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF D TH See Instructlons and exam les
<br />18. PART I. EMer the shain ot eveMe��disessea, in)uriea, or compllcadom-that directiy mused the death. DO NOT aMar termhrel everrta euch w aaNlac ertest, ; APPROXIMATE INTERVAL
<br />reaplreWry arreat, or re�nriwlar flbHllatlon isfthout showing the etlotogy. DO NOT ABBREVIATE Frrter ony ona wuse on a Iine. Add addlGonalli�rea If neeassary.
<br />IMMEDIATE CAUSE: ; onset to death
<br />n�uwre cause �i a) Respiratory Failure ` ; Less Than 1 Hour
<br />diaease or co�Mitlan reaulUng
<br />� d �� DUE TO, OR /69 A CONSEQUENCE OF: � onset to death
<br />s�v��rueeco�a�no,�,�r b)Acute Myocardial Infarctlon � LessThan 1 Hour
<br />erry. Ieadine � �e cause Ileted
<br />oh Ime a. DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />enmrnre unw�nNO cnuse �) �
<br />(dlaease or InJury that InitlateU �
<br />the evertte resuidng In death) DUE TO� OR AS A CONSEQUENCE OF: � o�et to death
<br />� d)
<br />18. PART 11. OTHER SIGNIFlCANT CONDRIONS�CorrcliUO� coMributl� to tha death but not resultl� in the underiytng cause gWen In PART I. 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED4
<br />� ❑ YES � NO
<br />� 20. IF FENULLE: 21a. MANNER OF DEATH Z1b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED7
<br />� � Nat P�9�M �+In pest year � Naturel � Homlcitle � DNvazlOperator �� � NO
<br />W � Pregnant at tlme oT death � Pasae�az
<br />V � AcWtleM � Panding Imeatigatton
<br />�+ � Not pre0nanf, but preB�eM �� 4� �e a deat� SutWee Coutd not be tlatemuned � P���" Z�d. WERE AUTOPSY FlNDINGS AVAILABL
<br />.o ❑ ❑ TO COMPLEfE CAUSE OF DEATH?
<br />� � NM P�eB�, but pre9naM 49 deYe to 1 year befora death � Otimr (Spectry) � YES ❑ NO
<br />m ❑ UNmown f( PreBnant widUn the P�Y�
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY�At home, tarm, atreet, faetory, oftica buliding, constructlon atte, etc. (Spacity)
<br />�
<br />.� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />� ❑ res ❑ No
<br />2�L LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNm (Mo., Day, Yr.) 24b. TIME OF DEATN
<br />�� S�� February 21, 2012 Approx. 02:20 AM
<br />� Z 23b. DATE SIONED (Mo„ Day, Yr.) 23c. TIME OF DEATH �� Q� 24e. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />Februa 13, 2012 02:47 AM
<br />$� � 0 3d. To the beat of my knowled8e. death axurretl at Ne tlma, date and Place � O
<br />24e. On the baeie o1 axaminatlon endlor ImeaUgation, In my opinlon death aCCUned et
<br />��� � and due W the Causele) efated. (918neWre end TWe) �� D Ure tlme. dale aM Plaw arM due to the oause(el sfetetl. (S18naN[e aad TItte)
<br />g s Jon Hendricks, Hall Deputy County Attomey
<br />2. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED4 28b. WAS CONSENT GRANTED?
<br />❑ YES ❑ NO ❑ PROBABLY � UNKNOWN ❑ YES � NO Not Applieable H 26a le NO ❑ YES ❑ NO
<br />2. TITL F ERT FIER (P Y C 1 S ANT, C RO E S P Y I OR (Type or rirrt
<br />Jon Hend�icks, Hall Deputy County Attomey, 231 S. Locust, P.O. Box 367, Grand island, Nebraska, 68802
<br />28a. REGISTRAR'3 SIGNATURE �- 28b. DATE FlLED BY REGISTRAR (MO.. Day, Yr.)
<br />February 21, 2012
<br />I
<br />
|