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<br />STATE OF NEBRASKA -
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASl.¢i �GP�R �OF�I�F,qLTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V�''ri�t� �E� , R��S .'' `°;� .
<br />x .' �,�'�i,� . ,,,' �
<br />DATE OF ISSUANCE �� ' � /
<br />� ��7 '' + i?�
<br />03/21 /2012 s��npt� 5: ��Q��R .� ,, �„ , �°
<br />2 012 0 4 41 � AS �.�G���R=� :
<br />QERAl�T1►7ENT Q,� HEALTH AND •; '
<br />LINCOLN, NEBRASKA HUNI, ;:' Y,` j',
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC��^ & v A �' y�+E� �� t,� ;� :` ', �, £' .12 00951
<br />i .6
<br />ctK i iric:P►i c �r ur,p►i n °,, ��: ,:
<br />1. DECEDENT9-NAME (First, Middle, Last, Suftiz) 2. SIX 5_ ,3. bATE OF dFATH �Mo., Day, Yr.)
<br />Kent Allan Grabill Male March-'f2, 2012
<br />4. CITY AND 9TATE OR TERRITORY, OR FOREIGN COUN7RY OF BIRTH 8a. AGE • Laet Birthday b. UNDER 1 YEAR 5c. UNDER 7 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y�•) MOS. DAYS HOURS NONS.
<br />Harlan, lowa 70 December 15, 1941
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />508 HOSPRAL � �npatlerR OTHE ❑ Nursl� Home1LTC � Hosplee Faefluy
<br />8b. FACIUIY•NAME pf rrot Instltution, gNe street arn! wmbe� ❑ ER/Outpatlent ❑ DeeedeM's Home
<br />K
<br />� Saint Francis Medical Center ❑ °OA � °�'�
<br />�a
<br />8c., CI7Y OR TOWN OF DEATH pnclude Zip Code) 8d. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />d 8a. RESIDENCE-STATE 8b. COUNTY 9e. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />� 8d. STREET AND NUMBER . APT. NO. 9L LP CODE 8g. INSIDE CITY UNO'fS
<br />" 615 S. Broadwell 68803 � r�s ❑ No
<br />� 10�. AAARITAL STATUS AT TIME OF DEATH � AAarri�l ❑ Never Martied 10b. NAME OF SPOUSE (Flrst, Mlddle, Last, SufN�c) H wHe, pive rt�alden rmme
<br />� ❑ nna��, but aeparated ❑ vinaowaa ❑ ��orcea ❑ unk�oam Mary Fay
<br />�
<br />11: FATHER'S-NAME (Firet, Middle, Laet, Sufflx) 72. MOTHER'SNAME (Firat, Middle, Malden Sumame)
<br />m Wayne R Grabill Adelafde Kirk
<br />Q ' 13. EVER IN U.S. ARMED FORCES? Gfve datea of service H Yes. 14a. INFORAMNT•NAME 74b. RELATIONSHIP TO DECEDENT
<br />$ (Yea, No, or unk.) Yes 07/23/1963-03/16/1969 Mary Grablll Spouse
<br />� 75. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />�? � eunai ❑ uo�eon paMcla R. Curran 1092 March 15, 2012
<br />❑ Crematlon Q EMombmerd 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (SpeeNy)
<br />Grand Istand City Cemetery Grand lsland Nebraska
<br />17a. FUNERAL HOIY¢ NAME AND MAIUNG ADDRESS (Street City or Town, State) 17b. Zip Code
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 68801
<br />AU OF DEATH See instructfons and exam les
<br />18. pART I. EMer the ehaln of eveMe--disaasea, InJurlee, or compOCatlon&thet tlIreWY aaused the death. DO NOT eMertermhmt eva� euch ae eardlac arreet, ; APPROXIAAATE INTERVAL
<br />� reaplratory arteat, or veM�iwlar flbriliatlon withou! showi� the etlolopy. DO NOT ABBREVIATE EMer only o�re ca�e on a Ii�re. Atld additlonal Ihree i( �ery. �
<br />' IMMEDIATE CAUSE: ; onset to death
<br />IMMF cnuse tfl� a) Aspiration Pneumonia � Days
<br />tli8ease or conditlon reauttlng
<br />�" p �'� DUE TO, OR AS A CONSEQUENCE OF: ` o�et to death
<br />s�,�am��r u�e ��areo�, n b) Cerebrdl Vascular Accident � Y��
<br />eny, Ieatling to ttie cause Oated '
<br />on une a DUE TO, OR AS A CONSEQUENCE OF: i orreet to death
<br />EMer the UNDERLYIN6 CAUSE C � i
<br />(disesee ot InJury that Initla[ed
<br />ure e"8"1° re�'�U"0 N deau'� DUE TO, OR AS A CONSEQUENCE OF: � o�reet to death
<br />'.asr d) �
<br />18. PART II.OTHER SIGNIFlCANT CONDITIONS-Co�itloire eoMributirig to the death but rrot resutting in the u�erlyi� eause given in PART I. 18. WAS MEDICAI. EXANONER
<br />OR CORONER CONTACTED?
<br />❑ YES � NO
<br />�
<br />W O.IF FENU►LE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION WJUR 21c. W/64 AN AUTOPSY PERFORMEDT
<br />F � Not P�9�t withln P� Y�� � r� ❑ Ho�m�iae ❑ orn.eova�rm
<br />U Pre9na�rt at dme of death ���ee� ❑ YES � NO
<br />❑ � Acdrle�rt � Pendlne Imesdgatlon
<br />� � Not prepneM, but prepnaM wtthln 42 daye ot death � Pedeatrlan 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />� euidae � cuuia na be aemmArred TO COMPLETE CAUSE OF DEA7H4
<br />� Not PreBnaM, but PreBna�rt 49 daye W 1 year before death � Otlrer ($P�tYI
<br />� � Unimown H P�9nant withln the va81 year ❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (Mo„ Day, Yr.) 22b. TIME OF INJURY Y1e. PLACE OF INJURY-At home, tarm, street faetory� ofttee bu��d�n8� co�uctla� $ke� etc• (Spe��FY)
<br />�
<br />� 22d. INJURY AT WORK7 Yle. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />❑ YES ❑ NO
<br />221'. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Ma, Day, Yr.) 24b. TIME OF DEATH
<br />.� W March 12, 2012 S�
<br />�� y 23b. DATE SIGNED{MO., Day, Yr.) 23e. TIME OF DEATH �� Y 24c. PRONOUNCED DEAD (Mo, Day, Yr.) 24d. TIME PR�NOUNCED DEAD
<br />� March 16, 2012 01:05 PM a�
<br />�'uZ
<br />$� � To the best M my Imow�edpe. deazd oaurted at tlre tlme. Aate and plaee $��� 24e. On the baele M a�raminatlon and/or ImeatlBadon. In my opinlon tl� occurred at
<br />$� anA due to tlre eauee(s) sfatetl. (Slpnature arM Tkte) � o � the tlme. date and plaee end due to dce eauae�e) sfeted. (Slpnetuie aml TIUe)
<br />~ Travis S. Hageman, MD `' g s
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED7 28b. WAS CONSENT ORANTED?
<br />Q YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Appllcable H 28a le NO ❑ YES ❑ NO
<br />27. IT AND D TIFI PHY 1 R R A ype or rint
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'3 SIGNATURE �+ ' 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />March 19, 2012
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