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<br />STATE OF NEBRASKA �� 1�,� O�l ���3
<br />WH�N TH/S COPY CARRIES THE RA/SED SEAL OFTHE NEBRASKA HEALTHAAiD HUMAN SERVICES �'
<br />SYSTEM, lT CERTIFIES THE BELOW TO BEA TRUE COPY OF THE ORIGINAL=RECORB�LE WFEH :_ .�
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL S?`ATlSTIG�C_�IC�AI, �A?I��UYS °•, _
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. __ = - '
<br />DATE OF ISSUANCE , � �^' ��-^ _ ��
<br />MAR 15 2�5 ' � _ r,�� � �oi?�
<br />ASSI�7'A� �FA�L��tE�I�TR� . _ ;'
<br />LINCOLN, NEBRASKA _ HEAL�QAI�I Hl[MAN�SERVIEE� =
<br />_ _ _ --- -_=-�' = _ = ,
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE qND.S�IPPOR�=-' `�
<br />CERTIFICATE OF DEATH �' � c
<br />�
<br />1, OECEDENT'S•NAME (First, Mlddle, Laet, 3uNix) 2.3EX 3.DATEOFDEATH (Mo.,Dey,Yr.)
<br />Wa e Eugene Ma Male March 8, 2005
<br />4. CITY AND STATE OR TERRITORY, OR FORE��N COUNTRY OF BIRTH 6a. AOE-Leat Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />Pierce County, Nebraska. (Yre.) 7( M03. DAYS Houas MINB. MS}� 1 �1 � 1928
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />507=30-9212 IiQS�LT96: ❑ Inpetient g1y�$ ❑NuraingHomelLTC ❑HospiceFactlUy
<br />86. FACILITY•NAME (If not inetitutlan, give etreet and number) � ER/OUlpeOent ❑ DecedenPaHome
<br />St. Franeis Medical Center ❑ �'+ ❑�e�csv�r)
<br />Bc. CITY ORTOWN OF DEATH (Inalude Zlp Code) Bd. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />9a. RESIDENCE•STATE 9b. COUNT7 8a CITY ORTOWN
<br />Nebraska. Hall Grand Isl�.nd
<br />9d. 3THEETAND NUMBER 9e. APT. NO 8f. ZIP CODE
<br />2530 N. Webb Rd 68803
<br />t0a. MARITAL STATUS ATTIME OF DEATH �1 Merrled ❑ Never Merried 10b. NAME OF SPOUSE (Flret, Mlddle, Lest, Su(tix) If arite, glve malden neme.
<br />❑ Martled, but sepereted ❑ Widowed ❑ Divoroed ❑ Unknawn I Ardi th C. Mort on
<br />12. MOTHER'8-NAME (Flrat,
<br />Millie
<br />18b. LICENSE N0.
<br />1092
<br />CITY / TOWN
<br />8g. INSIDE CIT/ LIMRS
<br />�I YES O NO
<br />Middle, Meiden Surneme)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />t 8c. DATE (Mo., Day, Yr. )
<br />March 11, 2005
<br />9TATE
<br />Remmel an0��s�ity� 3826 W. Stol�ley Park Rd Grand Isalnd, Nebraska. 68803
<br />17a FUNERAL HOME NAME AND MAILINO ADDRESS (&treet, City orTown, Slate) 17b. Zip Code
<br />Curran Funeral Chapel 3005 South Locust St. Grand Island, Nebraska. 68801
<br />11. FATHER'9•NAME (Flret, Mlddle, Laet, Sulfix)
<br />Arthur May
<br />13. EVER IN U.B. ARMED FORCES4 GNe dalea ol aeMce it yes. 14e. INFOHMANT-NAME
<br />(vea,no,oruntc.)Yes;6-15-51/5-1-52 Ardith C. r
<br />16. METHOD OF DISPOSITION 18a ER-SICiNATURE
<br />C�Burial ❑ Donatlon ' �,,'�
<br />0 Cremallon ❑ Entombment 18d. CEMETERY, CREMATORY R OTHER LOCATION
<br />0 ❑
<br />18 PART 1. Enter the nhaln nf even�s--diaeasea, lnjudea, or compticatione-thet direcdy caused the dealh. DO NOT en[ar terminel evenie auch ea cerdiac ertesl, ' APPROXIMATE INTERVAL
<br />I
<br />reapiralory anest, or venUiculer 11brIllaUon wilhoul shoaui� the etlotogy. DO NOT ABBREVIATE. Enter oNy one cauae on a IMe. Atld addittonel tlnea H neceseary. �
<br />IMMEDIATECAU9E: � onaettodeath
<br />ONMEDIATECAUSE(Flnel �e� ��� �� p �l1 lr M� N�CZ�1 a)� 2 � S\ � M� tJ J\ k. S
<br />mBe�emc�do��Id�B DUE T0, OR AS A CONSE�UENCE OF: I onaet W death
<br />dldeeth) I
<br />Sequeirtlaliy Iis! condidona, H ro) �_S �..� � � \ � ` �� ��� O � S � �� x, I �+� � 1 �
<br />�'����°g�O��� DUETO,ORA9ACON8E�UENCEOF: I onaettodeath
<br />on Idre a.
<br />EMer the UNDERLYIN� CAUSE
<br />(dlseaaeorMjurythetlnitteted �°�
<br />������^�) DUETO,ORA3ACON3EQUENCEOF:
<br />U�I'
<br />��
<br />18. PART II.OTHER SIONIFiCANT CONDITIONS-Conditions coniribuling to the death but nol reaulting in the underlying ceuse glveri In PART I.
<br />I
<br />� onset W dealh
<br />I
<br />I
<br />18. WA3 MEDICAL EXAMINEH
<br />OR CORONER CONTACTED7
<br />❑ YE3 � NO
<br />21 c. WAS AN AUTOP9Y PERFORMED?
<br />❑ YE9 �1 NO
<br />Pedestrlan
<br />❑ Not pregnent, bul pregnent wilhin 42 days of deafh ❑ gulcide ❑ Coutd nol be delertnlned 21d. WERE AUTOPSY FINDINQ9 AVAllhBLE TO
<br />20.IFFEMALE: 21a.MANNEROFDEATH 21b.IFTRANSPORTATION
<br />0 Not pregnant within past year � Naturel ❑ Homicide ❑ DrlverlOperator
<br />❑ Pregnam et Ome o( death ❑ Accident0 Pending Irnestlgallon � P�e�er
<br />❑
<br />❑ Not pregnant, but pregnant 43 deys to 1 yrear before death
<br />❑ Unknonm fl pregnant wllhin tha pest yeer
<br />22a. DATE OF INJUqY (Mo., Dey, Yr.) Ylb. T�ME OF INJURY
<br />� m
<br />22d.INJURYATWORK? 22e. DESCRIBE HOW INJURY OCCURREC
<br />❑ YES ❑ NO
<br />❑ Other (Speci(y) �pnqp� �gE OF DEATH7
<br />❑ YE8 ❑ NO
<br />22c. PLACE OF INJURY At home, ferm, etreet, fectory, oHlce bunding, conaWCUon elta, eta (Specity)
<br />22I.LOCATIONOFINJURY-STREET&NUMBER,APT.NO. CrtY/fOWN
<br />9DUE ZIP CODE
<br />23e.DATEOFDEATH (Mo.,Dey,Yr.) � 24a.DATESIaNED (Mo.,Dey,Yc) 24b.77ME0FDEATH
<br />.�� � ^ t) $ ^ Oj �� m
<br />� 23b.DATESIGNED(Mo.,Dey,Yr.) 23o.TIMEOFDEA ��� 24c.PRONOUNCEDDEAD(Mo.,Dey,Yc) 24d.TIMEPRONOUNCEDDEAD
<br />E�Z b3�0 -- OS �aS m a� m'
<br />$�� 23d. To the besi ol my knowledge, death occurred et the time, dele and place ���� 24e. On the besls ot examinetion endlor InvesUgation, in my opinlon deaU� ocourted at
<br />�� ue ro the ceuse a) elated. Signeture end Title ♦ � p$ the time, date eiM place azM due to Ihe cauae(s) atated. (Slgneture end TiUe )♦
<br />Ja �. 1.nc�e Z ^�fl ��
<br />25.DIDTOBACCOUSECONTR�BUTETOTHEDF�ITH9 28e.HA30R0ANORTISSUEDONATIONBEENCONSIDERED? 28b.WASCONSENTaRANTED7
<br />❑ YES NO ❑ PROBABLY ❑ UNKNOWN ❑ YES �.d,0 Nol Applicable if 28e le NO ❑ YES NO
<br />27.NAME,TI71E DADDRES30FCERTIFlER (PHYSICIAN,CORONER'SPHYSICIANORCOUNTYATTORNEI� (IypeorPrint)
<br />John�J. Cannella M.D. 729 N. Custer AV Grand Island, Nebraska 68803
<br />'8a. RE(iISTRAR'S SIDNATURE 28b. DATE FlLED BY RE�ISTRAR (Mo., Deg Yc)
<br />�, 6�A� 1 1 �00�
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