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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF MEALTH AND kIUMaN' 5ERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA= 9�P,�If� �M,�lU,7" OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSI7"ORY FOR VIT�iL BEC , `�,,
<br />P �^ t �` 4
<br />7
<br />( ; ��� �-�
<br />� DATE OF ISSUANCE � ,, ,, .
<br />{-0;' �� " _
<br />05�07�20,2 2 412 0 4 3 5 G STAI�I'��Y,S. COOPER , .�.�....-.�
<br />ASSIS �"AIV T Si��T��?�6�ISTF2AR :
<br />DEPA,R�NI�NT�� HfALT'H A/VD . : '
<br />LINCOLN, NEBRASKA HUMAIV�i9�ZVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES �� , ti�s � i` ;� �. 12 01618
<br />CFRTIFICOTF AF 1']FOTH `.6 �. �._.
<br />7 ------- ------ -- -------
<br />, DECEDENTS-NAME (Flrst, Middle, Last, SufPoc) 2. SIX �' '' ,,� 3: 11'T�'OF DEATH-(Mo., Day, Yr.)
<br />Julia lda Royer Female May 2, 2012
<br />4: CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Laet Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y►e•) d103. DAY3 HOURS MIN3.
<br />Logan, lowa 90 October 6, 1921
<br />7. SOCIAL SECURITY NUMBER 8a, PLACE OF DEATH
<br />480 &5449 �❑ Inpatlerrt OTHER � Nursing HomelLTC � Hosplce Faetitty
<br />Bb. FACILITY-NAME (Ii not Instttutlon, gWe street and number)
<br />� ❑ ER/Outpatlent ❑ DeeedenY's Home
<br />� Wedgewood Care Center ❑ ooa ❑ ou,er (sPeauy�
<br />� 8e. CITY OR TOWN OF DEATH (Include Ztp Code) 8d. COUNTY OF DEATH
<br />c Grand Island 68803 Hall
<br />� 90. RESIDENCESTATE 9b. COUNTY 8c. CITY OR TOWN
<br />Z i Nebraska Hall Grand Island
<br />LL 9{I. STREET AND NUMBER e. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY LIMRS
<br />� 925 Wesf John 68801 �� ❑ nto
<br />a 10a. NWRITAL STATUS AT TIME OF DEATH � Martled ❑ Never Marrled 10b. NAME OF SPOUSE (Firet, Middle, Last, Suffix) If wHe, give malden rmma
<br />9
<br />d
<br />� ❑ naamed, b�t �paracaa ❑ v�ndowea ❑ Dhrorced ❑ uow,own Joseph W Royer
<br />�' 11. FATHER'S-NAME (Firet, Middle, Last, SufPbc) 12. MOTHER'S•NAq7E (First, Middle, Malden Sumame)
<br />m John Hunt Effie Foglesong
<br />°' 13. EVER IN U.S. ARMED FORCES? Give dates of sarvice H Yes. 14a. INFORMANT-NAME 14b. RELATIONSMP TO DECEDENT
<br />E
<br />$ '(ves, No, or un�.) No Joseph W Royer Spouse
<br />,$ 7. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. UCENSB NO. 18c. DATE (Mo., Day, Yr.)
<br />F � Burlat ❑ Domatlon
<br />Tracey Dietz 1328 May 7, 2012
<br />❑ Crematlon Q EMombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 TOWN STATE
<br />❑ Removal ❑ Other (Speci(y)
<br />WesUawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MHILING ADDRESS (Street, Cily or Town, State) 17b. Zlp Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE OF D TH See Instructions and exam les
<br />16. PART I. Friter the chaln of eveMS-rliseasae, InJurtes, or compllcatlo�that dlrecfiy cau�d the death. DO NOT eMer terminal everns such as cardlac ertesR , AppROXIMATE INTERVAL
<br />�� resplratory artest, or ve�rtrlcutar N6d11atWn reithoul shawing the etlology. QO NOT ABBREVIATE. EMer only one cause on a tlne. Add adAltlonal qrtea N neeeseary.
<br />IMMEDIATE CAUSE: ; anset to death
<br />ieerneowre cause �nei a) Cardiac Arrest ; Minutes
<br />dleaa� or cond(Gon reauldng
<br />� d �'� DUE TO, OR i6S A CONSEQUENCE OF: ; o�et to death
<br />sem,am�any uas co�mumre, n b) Hypertension : Years
<br />am� ieadme m ure cause nama
<br />on Iine a DUE TQ OR AS A CONSEQUENCE OF: � omtet to deeth
<br />�m. ene un�u�ruao cause �)
<br />(�tisease or injury that initlated
<br />the eveMe reaulqng in deeth) DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />usT d � �
<br />76. PART II.OTHER SIGNIFlCANT CONDITIONS-Condidoris contributing to the death but not resulUng In the underiying cauae given In PART I. 19. WAS MEDICAL IXANONER
<br />Hyperlipidemia, Atrial Fibrillation, OR CORONER CONTACTED4
<br />� � res Q No
<br />� 2. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED9
<br />� � Not pragna�rt wkhln past year � Naturel � HoMdtle � Driver/Operator .
<br />U �� PregnaM a! tirta of death � Accitlent � Pendln8lnvesUgetiun � Peaeanger ❑� � NO
<br />� jQ Not pregnank but pregnairt wtth�n 4z days ot tleath � Pedestrlan 21d. WERE AUTOP$Y FINDINGS AVAILABLE
<br />Q Not pragna�rt, but pragnant a9 daye u 1 year oetore death � gw��de � Could nat be detertnUred ❑ � r �9��) TO COMPLETE CAUSE OF DEATH?
<br />�p Unknown If pregnant wdttNn the paat year
<br />❑ YES ❑ NO
<br />� 22a. DATE OF INJURY (MO., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, fa►m, street, factory, office bullding, correWCtion ske, atc. (Specify)
<br />s
<br />� 22d. INJURY AT WORK? 22e. DESCWBE HOW INJURY OCCURRED
<br />F�
<br />❑ YES �] NO
<br />22L LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (MO., Day, Yr.) 24b. TIME OF DEATH
<br />S � May 2, 2012 � � �
<br />� Y 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH �� k Y 24e. PRONOUNCED DEAD (Mo., Day, Y�.) 24d. TIME PRONOUNCED DEAD
<br />E Z Ma 4, 2012 09:40 AM � 6<�
<br />$ 0 2Sd. To the beet of my ImOwledge. tleath occurted ffi tlie dme. dete entl P��e $� � 248. On the h8818 Of W�enll�dOn 0ntl/m ItrvaBtigatloM � mi' oPln�on death oCCUrted et
<br />��� � and due to the ceusa(s) atated. (Signature and Tlfle) $ 0 the tlme, dele antl place and dua to the eause(e) sfated. (Signature and Tide)
<br />~ Jay C. Anderson, MD ~ ��
<br />2. DID TOBACCO USE CONTRIBUTE TO THE DEATH7 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applteable H 28a la NO ❑ YES ❑ NO
<br />2, E, TIT E AND ADDRESS F CERTIFI R(PHYSI , HYSICIAN ASSIST , COR NER'S PNYSIC R C NTY A ORN (Type or ri�
<br />Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />29a. REGISTRAR'S SIGNATURE �� 28b. DATB FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />May 4, 2012
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