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<br />STATE OF NEBRASKA =
<br />WHEN THIS COPY CARR/ES THE RAISED SEAL OF THE NEBRASKA HEA�.TH AM2b!!!$9i4ALSE
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGlNALI�OR_I�O�V_�
<br />THE NEBAASKA HEALTH AND�HUMAN SERVICES SYSTEM, VITAL STATI�C��EG�IQAF, �1
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - J
<br />DATE OF ISSUANCE _ E�' �
<br />JAN 0 3 2007 == �
<br />° as��r�rr srar� REG
<br />LINCOLN, NEBRASKA 2 O 1� o���� HEALF�AIIK���E
<br />STATE OF NEBHl�SKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE7kIdBSE1PPC
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<br />CERTIFICATE OF DEATH .- , ' '_: U V v L �°r r
<br />n,�w t. DECEDEN7'S-NAdAE (First, Middle, Laet, Suitlx) �G. SEX - 3:'DATE OF DEATH (Mo., Day,Yr.)
<br />���: A1yce Eleanor Graf Female November 28, 2006
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<br />`� 4. C�l'Y AND 3TATE OR TERRITORY, OR FOkEION COUNTRY OF BIRTH 6a. AQE•Laet Birthday 5b. UNDER 1 YEAR 6c. UNDER 1 DAY -' B. DATE OF BIRTH (Mo., Dey, Yr.)
<br />`�� Doniphan, Nebraska tv�a.� 92 MOS. DAYS HouRS MiNS. August 22, 1914 .
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<br />� 7. SOCIAL SECURITY NUMBER 8a PLACE OF DEATH -
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<br />505-72-�+I89 HOSPITAL ❑ mpenent � � NurehigHomelLTC ❑�HoeplceF9ciiity
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<br />��r � 8b. FACILITWNAME (�f not Instltution, glve atreet end number)
<br />� ❑ ER/Outpa8enl ❑ DecetlenYe Home '
<br />��un Hamilton Manor Care Home
<br />,t ,��? ' ❑ oa� ❑ omeresa�ir)
<br />� � t� Ba CITY OR TOWN OF DEATH pnclude Zip Code) ed. COUM Y OF DEATH
<br />'r`; Aurora 68818 Hamilton
<br />�� •i Ba.RESIDENCE-STATE Bb:COUMY Bo.Ct1Y0RTOWN
<br />'j�r Nebraska Hamilton Aurora
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<br />�� y �; 9d.STpEETANDNUMBER Be. APT. NO 8t ZIP CODE 9g. MSIDE CTfY LIMRS
<br />i 1515 5th St. 68818 � YES ❑ No
<br />��S t0a. MARITAL STATUB A7TIME OF DEATH ❑ Marcled ❑ Naver Married 106. NAME OF SPOUSE (Flrst, Middle, Leat, Suflbc) It wife, give melden name. � -
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<br />��r; ❑ Married, but seperaied G',�Wldowed �UNorced ❑ Unknown �
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<br />� � ti. PATHER'S•NAME (Firsl, , Middle, Last, Suftlx) 12. MOTHER'S•NAME (Firat, Mlddle, Meiden Surname)
<br />�i Benhart F1yr Tena Flessner
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<br />"=f+xk� 13. EVER IN U.B. AHMED FORCES7 Qlve detea of service If yea. 14a.INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
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<br />��!; '(Yes,no,orunk.) NO Gary Graf SOri
<br />�'`; 15. METHOD OF DISPOSRION 18e. EMBALMER-SIONANRE 18b. LICENSE N0. 18c. DATE (Mo., Dey, Yr. )
<br />��'� t$s��ai� 000�no� �� ��3��'' December 2, 2006
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<br />r,,+'r ❑ Crema6on ❑ F�tombment ��d• CEMETERY, CREMATORY OR ER LOCATION CITY / TOWN STATE
<br />' ���� ❑Removai ❑Other(9pecily)
<br />, ; Cedarview Cemetery Doniphan . Nebraska
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<br />{Y� x� 17a FUNERAL HOME NAME AND MAILINO ADDRE38 (SVeet, Ctty orTOwn, StateJ 176. Zlp Code
<br />�� Apfel Funeral Home, 1123 West Second, Grand Island, NE 68801
<br />} I � '�. ��� � V. Y 3 ^i� .N fi �� Z SS ., � � ���.. � X'�� •. �� ��v���,u�Fkd�A�"2 . � ��� � ,�' : k � ��x. ..:4 j + I � � 9 � _
<br />,� �'��u> � dt� ,� �e � { �ti �,�.a .e€'? i� b �� � . w-, s 2 ,_n��� �.. �:< �'� � �.��
<br />1& PART I. Enter the chain ot evenis-dlseasea, Injurles, or compllcaUons-that directiy ceused the death. DO NOT enler terminet evente auch as cardlac arcast, � � APPROXIMATE INTERVAL �
<br />�,��,, reaplrelory erreat, or yenlriwter fibdllailon wfthout ehowing the eUology. DO NOT ABBREVIATE. Enter only one aauae on e Me. Add addltlonel Ilnes If neceseary. i
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<br />,, ay, ; IMMEDUVTE CAUSE � onaetro deatl�
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<br />�� �''` @4MEDUITECAU9E(Flt�l (�� 1
<br />F� �'
<br />��?%`4� m�oro°^dRt°nr�uRNB DUETO,ORASACON3EQUENCEOF: I misettodealh
<br />{ J Indeath) I
<br />"��''� ro� ' 7 � y ea�n,
<br />; ,�e r ,,.� sequendanynstcondHlons,n _ �
<br />,'°"'' etty,teadlhgtothacauseiistad DUETO,ORASACONSEQUENCEOF: � onse�lodeath
<br />���;� onlhrea �
<br />� �5x'` ENa�theUNDEHLYWOCAUSE
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<br />r�,:; (mse�eorinJuryUmtinitlated �°�
<br />� N ��� �� 10 �� DUE TO, OR AS A CONSE�UENCE OF: � onset to death
<br />h!.°; ��� Ul'il' � � - �
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<br />� k ���,# 18. PART II.OTHER SIaNIFICANT CONDITIONS-Condidona contribuiing to the death but not reaulting in the underlying ceuse glven In PART I. 18. WAS MEDICAL EXAMINER
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<br />r i,� � '�� ��� OR CORONER CONTACTED?
<br />� � ❑ YES 0 NO
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<br />� ; 20.IFFEMAIE: • 21aMANNEROFDEATH 21b.IFTRANSPORTATIONINJURY 21aWASANAUTOPSYPERFORMED7
<br />, i ❑ Nol pregnant withln peat year .�Natural ❑ HomicMe ❑ DrIveNOperator
<br />' tY ❑ Pessenger d YES �10
<br />�� ❑ Pregnant et ilme ot death ❑ Axideni0 Pend(ng Investlgatlon
<br />y,tl ,:.x ❑ PedeBMan �
<br />� ❑ Not pregnenl, but pregnent wMin 42 deys dt death ❑��cide ❑ Could not be detertnined 21d. WERE AUTOP3Y FlNUIN�3 AVAILABLE TO
<br />, R � � � ❑ Other (SP�Y)
<br />'�- '7 ❑iVoipregnant,butpregnent43dayslolyearbeloredeath COMPLETECAUSEOFDEPSH4
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<br />,�; � ❑ Unknown If pregnanl withln the peat year 0 YES �'NO
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<br />22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home,larm, street, lactory, offlce bultding, conaWcUon elte, eic. (Specity)
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<br />���� 22d. iNJURYATWORI(T , 22e. DESCRIBE HOW INJURY OCCURREb _
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<br />❑ YES ❑ NO
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<br />221. LOCATION OF INJURY - STREEf & NUMBER, AP7: N0. CITYlfOWN SDUE ZIP CODE
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<br />� k � i 23a. DATE OF DEATH (Mo., Day, Yf.) � 24e. DATE SIONED (Ma, Oay, Yt.) 24b.TIME OF DEATH
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<br />� ��� 23b.DATE8I�NED(Mo.,Day,Yr.) 23a.TIMEOFDFATH ��k 24a.PRONOUNCEDOFJID(Mo.,DegYrJ 24d.TiMEPRONOUNCEDDEAD
<br />?�d z December 2 200 `7 ^� A m E� a � Z � m
<br />�,� •r �� 23d.To the best ot my knowledge, death occurced et the time, date end place $ w�� 24e. On ihe beals of exeminaUon endlorinvestlgaUon, in my apinlon death oxurred at
<br />�°- `-" .� e end due to the ceuse(s) tated. (Signature anQ TiNe )� .� p� tha tlme, date and p�ace end due to ihe cause(s) sleted. (91gnaNre e� Title )�
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<br />4 ` 26.DIDTOBACCO USE CONTRIBUTETOTHE DEATHI 28a. HA3 OR�AN OR TIS3UE DONATION BEEN CON31DEpED7 28b. WAS CONSENT QRANTED?
<br />' �i ❑ YE3 �NO ❑ PROBABLY ❑ UNKNOWN �I'YE9 ❑ NO NotApplica6le If28alsN0 ❑ YES �NO
<br />� 27.NAME,TITLEANDADDRESSOFCERTIFIER (PHYSICIAN,CORONER'SPFIY3ICIANORCOUNIYATTOHNEI� (TypeorPdnt)
<br />„i Michael Sullivan M.D. 609 "0" St. Aurora, NE. 68818
<br />28a. REQISTRAR'S 3I(iNATURE 286. DATE FlLED BY REOI3TRAR (Ma., Day, Yc)
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