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<br />- STATE OF NEBRASKA �� 1� Q 4 3 Q Q
<br />WHEN THIS COPYCARRIES THE RA/SED SEAL OF THE NEBR.4SKA HEALTHAND HUMAN SERVICES
<br />SYSTEM, IT CERT/FIES THE BELOW TO BEA TRUE COPY OF THE OR/GINAL REGORQ�11t FIGE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERV/CES SYSTEM, VITAL STAT/STICS SEF�IaAF, WYf/CH /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF /SSUANCE ' � `�" �'�" ��+ � :
<br />DEC � 6 2007 �"' � � r��u�.�%�=��o��R .
<br />ASSXST�I��.i',4�"E A�lS'�A14
<br />L/NCOLN, NEBRASKA H�ft�AIVD �l�ll�� SEt�V1EE�
<br />; 1� �.�.� ��, � � : e
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AIVD HUMAN 5�RVICES�INANEE AAIE3SUP
<br />CERTIFICATE OF DEATH �_> '�r a:-' .. (,y�° 3 2 7 9 �
<br />1. DECEDENT'9•NAME (Firat, Mitltlle, last, 3uH(z)I 2.SE'Xi'�: `, 3,.UATEOFDEATH (MO.,Day,Yr.)'
<br />Llsie M. Lilieathal �'�ma�lq •, November 24, 2007
<br />4, CI7'Y AND BTATE OR TERRITOAY, OR FOREICiN COUNTRY OF BIRTH 6a. AflE�leat BlAhday 6b. UNDEH 1 YEAR Ho. UNDER 1 DAY 8. DATE OF BIATH (MO., Dey, Yr.j
<br />(Yte.J MOS. DAY9 HOURS IdINS.
<br />Alda, Nebraska g2 July 10, 1915
<br />7. SOCULL 6ECURRY NUMBER Ba PLACE OF DEATH
<br />506-18-6319 y08PITAL: ❑ �npattent � �NuraingHomelLTC oHos�ice�acmry
<br />8b. FACILITY-NAME (If not Inatliullon, gfve etreei and number) ❑ ER/Outpetlarrt ❑ DecedenYsFtome
<br />Golden Living Center Lalcevie� o � ����,�
<br />8c. CITY OHTOWPf OF DEATH (Include Zlp Code) Bd.COl1NTY OF DEATH
<br />Grand Islaad, 68801 Sall
<br />9aAESIDENCE3TATE 9b.C6UNiY 9c.C1TY0RTOWN
<br />Nebraska Hall Grand Island
<br />8d.9TREE7AND NUMBER 8e. APT. NO 8f. ZIP CODE 9g. INSIDECITY LIMRS
<br />1�405 8ighway 34 W 68801 � rea o No
<br />t 0a MARITAL B'fATU3 ATTIME OF DEATH 0 Martied O Never Merr[ed 10b. NAME OF SPOUSE (Flret, Middle, Lesl, SuHBc) If wife, give maidan nema
<br />❑ Merrled, 6ut separated �Wldovred ❑ Dhrarced ❑ Unlmown
<br />17. FATHER'S-NAME (Piret. M(ddle, Lasl, Suffix) 12. MOTHER'9-NAME (Flret, Middle, Malden 6umame)
<br />�
<br />William Luth Dora
<br />13. EVER IN U.S. ARMED FORCES? tihre datea ot aervicelt yea. 14a.INFORMANT NAME
<br />(Yes, no, or unk.} NO COZZBeIl C3=By
<br />16.METFIODOFOISPOSITION 7, B�tACER•SICdWAAR1HE -OJ / iBb.LICENSENO.
<br />�Btuiel ❑DW�edon (� f � �.�Q2
<br />❑ Crematbn ❑ Emambment 18d• CEk1ETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />❑a� ❑ana�tsv�iy� Grand Ialand City Cemetery Graad Island
<br />17a FUNERAL HOME NAME AND hU11UNQ AOOREBB (BVaet, Criy orTomm, 31a1e)
<br />Curraa Funeral (�apal 3005 South Loaust Street ; Grand Islead, 1�
<br />Nissea
<br />74b. RELATIONSHIP TO DECEDEN7
<br />t 60. DATE (Mo., Day. Yr. )
<br />Notr 28, 2007
<br />STATE
<br />1QE
<br />1)b. Zip Code
<br />68801
<br />1& PART I. Enter the ebafn at evente-dfaeeaes, injuriea, or compllcaUona-that directty ceused the death. DO NOT eMer terminel evente such as cardtaa ertest, �'rttuamuw� n w� er+v�
<br />I
<br />reapiratory artes4 m renlricuier tiEriAetlon wlthout ahcwing tha etlNogy. DO NOT ABBREVUITE. ENer onty one cause on a qne.Add edditicnai Ih�es U neceasary. �
<br />IMIdEDllITE CAUSE � a�e110 tleath
<br />. I
<br />�AEDWTECAUSE(F[oel �� � °'-'?"��� � i
<br />��'�� DUETO,ORASACdNSEQUENCEOF: I onsettadeath
<br />tn deethj 1
<br />Seque�Ilyilete0edRlene,H ro� I
<br />anY.�dhgtetlmmu�lis� I
<br />DUETO,ORASACON9E�UENCEOF: I onsettodeelh
<br />��� I
<br />Fi�azl}�e{��HIYtl�OCAIISE i
<br />(d�armjuryu�ettnnlsted (°� �
<br />������ .DUETO,OAA3ACONSEOUENCEOF: i �m�t�°deaU'
<br />� I
<br />�� I
<br />18. PART II.OTHER SICiNIFICANT CONQITIONS-Comifttona caiMbudng io the death but rrot reaWdng in the widarlyfng muse glven N PART I. 19. WA6 MEDICAL EXpMINER
<br />OR CORONER CONTACTED7
<br />❑ YES � NO
<br />20.IFFEMALE: 21a.MANNEROFUEATH 21hIFTRANBPOFiTATIONINJUAY 21aWASANAUTOPSYPEHFORMED7
<br />,� Not pregnaM wtthin pflat year ���� ❑�� ���� ❑ YES f$NO
<br />❑ Pregnent at time ot daeth ❑ Accldent0 Pe�Mi� InvaeUgatlan ����
<br />0 Not pregnant, but pregnanf withUi 42 daya of death Q Suldda ❑ Could rtot be deterM�retl ❑ P��� 21d WEREAUTOPSYFWDMQ9 AVAILABLETO
<br />�NotPregnan6bulpregnarit43dayerolyearbetoretleath ❑Other(SPed(y) CAA�LErECAU9E0FDEATH7
<br />❑ UnknovmHpregnantevithlnthepastyear ❑ YE9 ❑ NO
<br />22a. DATE OF INJl1RY (Mo., Oay. Yr.) 22b. TIME OF INJURY 22c. PLACE OF WJURI'-At home, farm, street, iectory, cffice buiidin8. conaVUCtlon ske, etc. (Specity)
<br />m
<br />22dW,lURYATWORK7 72e.DESCRIBEHOWiNJl1RY0CCURRED
<br />❑ YE6 ❑ NO
<br />22t LOCATION OF INJUHY • 87REET � NUIdBEH, AP1: N0. CtIYlfONiW STI�E ZIP WDE
<br />23a. DATE OF OEATH (Mo., Day, Yr.) z � 24a. DATE SIQNED (EAa, Day, Yr.) 24dTIME OF DEATH
<br />.8'� tl - 'a-y . zoc.7 �F�� m
<br />�� 29b. DATE &IONED (Ma., Dey, Yr.) Y,ic.TIME DEATH �� 24c. PRONOUNCID DEAD (6Ao., Dey, Yr.) 24d TqNE PRONOUNCED DEAD
<br />� �¢ �� • 3�, �,.s7 . m ��<Z m
<br />�� � 23d.To the hesl af my knamtedge. deaih occurted et the tlme, dete end iace �i � 24e.On ttre Imsis af exeminedon aMlor Irneadgadon, in my opWon death occurted et
<br />en due ro th use( etated. (Stgnature and TIUe )♦ �� thetlme, date and piace ertd due ro ihe cause(a) etated (SlgneNre and TtUe )♦
<br />F � � ro� �•c� �� ~ C� � . .
<br />25.DIDTOBACCOUSECONTRIBUTETOTHEDEATFI7 28a.HA30R0ANORTISSUEDONAT10N8EENCONSIDERED7 28b.WA&CONSENTORANTED?
<br />Q YE9 �. NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Appllcebie If 28a fe NO ❑ YES � NO
<br />27.NAME,TI7LEANDADDRE330FCERTIFlER (PHY9ICWN,CORONERBPHYSICIANORCOUMYATTORNEI� (rypeotPrint)
<br />Doaald G. Airth M. D. 2116 W. Faidley Ave. #400, Graad Islaad, 1� 68803
<br />28a. REti13TRAR'S &16NATURE / 28h. DATE FlLED BY REOISTRAR (Mo.. Day, Yc)
<br />'' DEC ,4 2007
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