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STATE OF NEBRASKA
<br />WHEN THIS COPY GARRIES THE RAISED S�'AL OF' THE NEBRASKA DEPARTMENT OF HEALTH AJVD UNIAl1j S'�RVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASI(<J Q�.P�TM�N7''QF H�A, LTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WH�CH IS THE LEGAL DEPOSITORY FOR VIT�QL R �� . y y . , Q�� .' r, ';±
<br />. � � , - . , y • ,�, `. � ti �-„ � -�
<br />DATE OF ISSUANCE � �C.i� • �� -"•, ;� , , , N �
<br />2 0�. 2 a 6 7� 4 ����'� ;,,, .
<br />� 05/15/2012 � � sr�l�u�r s. �cop,ver� � ,
<br />i4S51�;TANT�S'Ti4T�-R�1�'fR,4 r�� �
<br />' DE1��IR-TA7ENT OF HEALTH A�� : �
<br />LINCOLN, NEBRASKA HUI'!�JA�1Z�5EI��,CES � �.,-° r '�
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERWCyES�`� �����"�� ��� �
<br />-------- --- -- - � � �. ..... P,"�' � . 12 01710
<br />ctK� ir��Ai t �r u�►i M • � ,. � • ; , � � _ -
<br />1. ECEDENTS-NAME (First, ' Middl�, Last, SuftG[) 2. SD( 9. DATE OF DEATH (Mo, Day, Yr.)
<br />IlElsie Evel Moss Female May 3, 2012
<br />4. , I7Y AND STATE OR TERRfTORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo„ Day, Yr.)
<br />(Y�•) MOS. DAYS HOURS MINS.
<br />' helton, Nebraska 98 j August 3, 1913
<br />7. &OCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />'�i08-60-2435 �,4 Q �rtpaUent OTHER � Nursl� Home/I.TC � Hospice Faelllty
<br />B�, FACILII'Y•NAME (11 rrot Instfdrtlon, 81ve street and numbe�
<br />� a �,�de� ❑ �a�e Ho�
<br />� Keamey County Health Services LTC ❑�A ❑�►(sa�Kr1
<br />� ec. C7T'Y OR TOWN OF DEATH pnelude Zip Coda) 8d. COUNTY OF DEATH
<br />o Minden 68959 Keamey
<br />� 8a RESIDENCESTATE 8b. COUNTY 8c. CIIY OR TOWN
<br />Z Nebraska Keamey Axtell
<br />� 9d4 BTREET AND NUMBER . APT. NO. 8L ZIP CODE 9g. INSIDE CITY LIMITS
<br />�884 27 Road 68924 ❑ ves � No
<br />� 10�. MWRITAL 9TATUS AT TIME OF DEATH Q Martled ❑ Never Nlartl� 10b. NAME OF 9POU98 (F6st, Npddle, Laet, Suftbc) H wife, gNe maiden name
<br />� 'p ro�mea, d�c ser+��ea � vinaowea ❑ oivorc� ❑ unkeown Willlam E Moss
<br />� 11 � FATHER'S-NAME (Firat, Mlddie, Last, Sufti�cl 12. MOTHER'S-NAME (Flrst, Mlddle, Maiden Sumartre)
<br />Joseph Quaring Mna Klinkacek
<br />Q ' 13: EVER IN U.S. ARMED FORCES? Give dat� ot a8rvice H Y�. 14a. fNFORMANT-NAME 14b. RElAT10NSMP TO DECEDENT
<br />6
<br />g �res, No, o. unk.► No Jenil Andersan Daughter
<br />,� 15.� METHOD OF OISPOSI770N 18g. EMBALMER-SI�NATURE 18b. LICENSE NO. 18c. OATE (Mo, Day, Yr.)
<br />F � Budal ❑ Do�aon TrdCey Dle� 1328 May 8, 2012
<br />Q CremaUon, � BMombmeM ��, CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN 9TATE
<br />t`J Remavai ❑ o�,ar (specrry� W��awn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND NWUNO ADDRESS (Streeq Ctly o► Town, State) 17b. Zip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebrdska 68801
<br />U E F D TH See Instructlons an e�cam les
<br />t& PART I. EMer the �hatn M eva�As-dbeaees,�Mjuriea, or compRcatlonrUtst direotiy mtaed Bie deaN. DO NOT e�rter terminal evenm suci� ae cardtac aneat, = APPROXIMATE INTERVAL
<br />�. reaPlraWry e+reet, Or ventrlwtar Nbrl�atlon wffhout Mo�dn9 ths eUOlopy, � NOT ABBRHVIATE. F.nler oNY are cq�e on a IUre. Add eddlUo�ml Orres B �rewesery. �
<br />IMMEDIATE CAUSE: ; onset to d�th
<br />n�nxeowre cnus� �nai a) Fleart Failure � Years
<br />dls9ase or condRton reeulBng , .
<br />��� DUE TO, OR AS A CONSEQUENCE OF: ; or�set to death
<br />BeiNeMla�y Ost cohditim�a H b}
<br />anY. IeadinB to tl�a rauea Uffied '
<br />O11 ��� a OUE TQ OR AS A CONSEQUENCE OF: = onaet to death
<br />E�r n�e uNUERLYwO CAUSe G � � �
<br />(diseese m In1�Y dnt Initqded . . .
<br />the evema reeutUne In deat�) DUE TQ OR AS A CON9EQUENCE OF: j o�reet to death
<br />� d) _
<br />�
<br />19. PAR7 U. OTHER SIGNIFlCANT CONDITIONS�Candltloire contrlbuling to the death but not resuiting in ttre urWeriyi� puse glven In PART 6 19. WAS MEDICAL EXAMINER
<br />Aortic Valve Replacement OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />LL 0.1� FEMWLE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AVTOPSY PERFORMED7
<br />F� [] nroe �a�n.nnu� v�e rBa. � r� 0 Hoouaa. ❑ ornrenov�► 0 y�s � No
<br />v � r.�M m n� m ew, � n�aa�u � aa� �aaenoo ❑ a86�"sa•
<br />� Na �M, mn ore¢naM r►�m az days or aeau� � veaesu�n 27 d. WERE AUTOP3Y FlNDINGS AVAILAB
<br />� q Not P�e9�R but P�ee�ae149 daya ro t year betore deaM ❑�dde � eoWd not be determined � Other (SPedb) TO COMPLETE CAUSE OF DEATH4
<br />� ❑ Untmown H piegnant.Wtln ere a� rea► � ❑ YE3 ❑ NO
<br />� 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, fartn, str�t, featory+, oftlee bWWi�, co�retructlon sibe, ete. (Speeify)
<br />� ,
<br />.� 22d. INJURY AT YYORK7 2'!'e. DESCRIBE HOW INJUI2Y OCCURI2ED
<br />I�-
<br />❑ YES [] NO
<br />22f. , OCATION OF INJURY • STREET & NUMBER, APT.NO. CITYlTOWN STATE ZIP CODE
<br />23a. DATE OF DEATFt (Mo„ Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. 71ME OF DEATH
<br />.� ��, May 3. 2012 S � � - - - - -- -----
<br />��„ Z 23b. DATE SIONED �Mo., pay, Yr,� 23c. TIME OF DEATH �� Y 24c. PRONOUNCED DEAD (Mo., Day, Y�.) 24d. TIME PRONOUNCED DEAD
<br />Ma 4 2012 � 04:20 AM � �
<br />$� 0 To the Dest oi mY I�rled9e. death oewrted et tAe dme. date antl plaee � 24e. On tlre beafe MexaMnadrn anNOr ImestigaGon. In rtry opWon Aeath ocwrte0 at
<br />�-�� and due to tlre �Isl �. (319nedrte and Tlttel o� Itre time, date mM p�ace anA due to Lhe eauae(e) etaoed. (Signature an0 7Rte)
<br />~ ��' Douglas Althouse, MD '" � a
<br />28. ID TOBACCO USE CONTRIBU7E TO THE DEATH? 28a. W69 OR(iAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT f3RANTED7
<br />YES � NO ❑ PRO�ABLY ❑ UNKNOYYN ❑ YES � Nb Not Appl(cable H28a ta NO ❑ YES ❑ NO
<br />ITLE D AD F E IFI (P i R ype or M
<br />pouglas Alfhouse, MD, 727 E. 1st Streek Minden, Nebraska, 68959
<br />ZSa. I �tEG19TRAtr3 SIGNATURE 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />May 14, 2012
<br />�X�ft�7j� f
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