|
� � � S'LATE OF NEBRASKA
<br />WHE:11, TH1S COPY CARRIES THE RAISED SEAL OF THE NEBFL4SKA HEALTH ANQHUMAN SERV/CES
<br />J1�ST�'M, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE OR/G/NAL�E�DRF�CJN F1LE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERV/CES �YSTEM, VITAL STAT�TICS SE�TlElio; i�1lH/CH /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. __ _ -
<br />DATE OF ISSUANCE � �
<br />, '^'.Q . -
<br />209.206899 ..-1 -- A�����A
<br />LINCOLN2NEB�RAoKA 2 0 0 5 0�. 3 4� FI�TI� �_ND HtIMrAN SEAYfCES
<br />-. - .
<br />-� - -
<br />-_: ��.;---._-_:__.-_
<br />_._- - -
<br />_ _ "-- _ �
<br />o�rucvriv�enr�arw-u�rran DEATH '�t�rinu�rv�t�rvusurrur+i O � O o r� p�
<br />? L�
<br />���; 1. �ECEDENT'S•NAME (Flrei, M(ddle, Lesi, Sulfix) 2. SEX 3. DATE OF DEATH (Mo., DagYrJ
<br />r�,�� Donna May Towler Female January 13, 2005
<br />� "� <
<br />�:; 4. CITY AND SiATE OR TERRITORY, OR FOREI�N COUNTRY OF BIRTH 5a. AOE-Lest Blrthday 66. UNDER 1 YEAR 5c. UNDER i DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />" F= Shelton, Nebraska cY�e.) 68 MOS. DAYS HouAS MiNS. September 12, 1936
<br />i� � t
<br />7. SOCIAL SECURITY NUMBER
<br />��, Be. PLACE OF DEATH
<br />� ``? 508-40-1343 HOSPITAL ❑ mpanent � , ❑ NuralrtgHoma/LTC ❑HoeplceFacillty
<br />f, � :
<br />�°-: Bb. FACILITKNAME (H not Inatitutlon, give atreet and number)
<br />; ❑ ER/Outpatlent � DecedenPsHOme
<br />; Home: 1152 S. Greenwich ❑ � ❑ ��� s �,�
<br />�'�"' 8a CITY OR TOVJN OF DEATH (Include Zip Code) Bd. COUNTY OF DEATH
<br />t ,.
<br />ii
<br />_, � Grand Island 68801 Hall
<br />-+? �;l# 9a.RESIDENCESTATE 86.COUMY Bc.CiTYORTOWN
<br />�,`,' Nebraska Hall Grand Island
<br />; 9d. STREETAND NUMBER 9e. APT. NO 8f. ZIP CODE Bg. INSIDE CRY LIMITS
<br />����. ''��; 1152 S. Greenwich 68801 �7 ves �. ❑ No
<br />,, ,
<br />�' j! 10a. MARITAL STATUS AT TIME OF DEATH ❑ Marded ❑ Never Merried 106. NAME OF SPOUSE (First, Middle, Leai, Suffl�c) fl wHe, give meiden name.
<br />'"` ';, ❑ Marrled, but sepereted � Widowed ❑ Divorced ❑ Unknown
<br />i' `� 11. FATHER'S-NAME (Firet, Mlddle, Last, Suitlx) 12. MOTHER'8-NAME (Ftrst, Middle, Melden Sumeme)
<br />�i
<br />�+,� Frank T. Clark Lydia Gehring
<br />�°-' 13. EVER IN U.S. ARMED FORCE84 �ive datea of aervica It yea. 14a.INFORMANT NAME 146. RELATIONSHIP TO DECEDENT
<br />i ��
<br />�,; (Yea, no, orunk.J NO Rodney Towler SOII.
<br />h;
<br />+'�'i 15. METHOD OF DI3POSITION 16a E AL ER-SIQNA R i8b. L�CENSE N0. 18c. DATE (Mo., Day, Yr. )
<br />„� ,n �.1 [�BUrIaI ❑ DoneNon 1
<br />2�0 January 17, 2005
<br />0 Cremeilon ❑ Enlombmeni 18d. CEMETERY, CREMATO R 0 HER LOCATION CITY / TOWN STATE
<br />�""�' O Removal ❑ other (Specity)
<br />��" Cameron Cemetery Wood River, Nebraska
<br />�'��-
<br />����� 17a.FUNERALHOMENAAqEANOMAILINOADDRES3 (Street,CNyorTovm,3tete) 17b.2ipCode
<br />����;!; Apfel-Butler-Geddes Funeral Home 1123 West 2nd, Grand Island, NE 68801
<br />" ��,ii,. �"�„�„ ���.�,�.x ���a F7 5 0 .�:,}�?h,j��� ffi� l'�ro#idPi� �;htf� �x� t' ,;� ' �'
<br />.,,y ..�._. _,. . . . . . .., � ;. . ,. , _ ,. . .,, ... , . _ ,.:•;_. , . ,
<br />18. PART I. Enter the chein ol eventa-diseases, InJurles, or compllcaUona-thet direcliy ceused the dealh. DO NOT enler lerminel eventa such ae cardiac arreat, APPROXIMATE INTERVAL
<br />I
<br />'=3, ,r� respiretory aneat, or ventdcular iiHdllatlon wilhoul ehowir�g the ellotogy. DO NOT ABBREVIATE. Enter onty one ceuae on e line. Add addmonal Iinea f� necessary. �
<br />r� � �
<br />IMMEDIATE CAUSE: mmet to deafh
<br />'_ �;;ii I
<br />� I i) (e � V � /��i/ ,G . � `
<br />� i. RdMEDIATECAUSE(Fl�rel .,. � /*' � c-*, � �/.h o / tl.
<br />'= diseaaeorcondltlonreau +
<br />-;�.,��;7�; � DUE TO, OR A8 A CON3E�UENCE OF: I onsetto death
<br />�rbF� Mdeeth) 1
<br />i a t" � �
<br />SequeMlal�ytlsteondNione.H ro)
<br />rAt e m'��� ^ B tO ������ DUETO,ORASACONSEQUENCEOF: I onsettodeath
<br />+ �.•� onli�a
<br />,�ry: E�riheUNDERLYMaCAUSE �
<br />, t;: (diseaseurin�urythetWtieted (°) �
<br />I ?. iheeventareauNnglndeath) pUETO,ORASAC6N3E�UENCEOF: � onsettodeath
<br />'a 9r �
<br />I� i�' �
<br />7;, i'' (� �
<br />18. PART II.OTNER SIONIFlCANT CON ITIONS-Conditlona conlribuAng to the death but not reaulHng In the underlying ceuse ghren In PART I, 18. WAS MEDICAL EXAMINER
<br />a '
<br />��;�,yr ' �n'Vt`� � ���1 ,/� .r� / � OR CORONER CONTACTED?
<br />:;'Ji7, O "'° /� �/�/��/� / ❑ YES �10
<br />�j �' 2�0.IFFEMALE: 21a. EROFDEATH 21b.IPTRANSPORTATIONINJURY 21c.WASANAUTOP5YPERFORMED9
<br />�' fd Nol pregnenl within past year �turel ❑ Homlolde ❑ Driver/Operator �/
<br />,�?� ❑ Pregnant at time ol death ❑ AccldentO Pending lrnesdgatron
<br />❑Passe�er ❑ YES �"NO
<br />;�+„ ❑ Not pregnent, but pregnant wllhin 42 deys ol death ❑ gWcide ❑ Couid not 6a tleterminetl � Pedeatden p�d. WERE AUTOP9Y FlNDIN6S AVNLABLE TO
<br />�. ❑ Nat pregnent, but pre nen143 de to 1 ❑ 01her (SpecityJ
<br />g ys yearbetoredealh COMPLETECAUSEOFD 7
<br />' ❑ Unknown H pregnenl wllhin Iha peat year ❑ YES 0
<br />22a. DATE OF INJURY (Mo., Dey, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY At home, term, street, taclory, offlce bullding, conatructlon alte, elc. (Specity)
<br />-"�♦W��.��. m
<br />" N=` 22d.INJURYAT WORK9 22e. DESCRIBE HOW INJURY OCCURRED
<br /><:�i; ._
<br />❑ YES ❑ NO
<br />; ,
<br />22t. LOCATION OF INJURY- STREET & NUMBER, APT. N0. CIIY/fONM S7ATE ZIP CODE
<br />'n - �
<br />_",
<br />23a.DATE0F0EATH (Mo.,Dey,YrJ � ' � 24a.DATESIONED (Mo.,Dey,Yr.) 24b.TIMEOFDEATH
<br />.�� January 13, 2005 ,��� m
<br />�� 23b.DATE8IQNED(Mo.,Day,Yr.) 23c.TIMEOFDEATH ��� 24c.PRONOUNCEDDEAD(Mo.,Dey,Yr.) 24d.TIMEPRONOUNCEDDEAD
<br />�
<br />;;,o anu 3 2 05 5:1.5a m E�`Z m
<br />�.5 23d.To the beat of my knowledge, death occurted al Ihe time, date a� place $��� 24e, On the basls ol ezeminellon end/or Investlgetlon, In my opinlon death owuned al
<br />. F � end due fo lhe,CaO§e s s4et� �'Signeture and Tltie ) 0 .� �� the Ume, deta end place and due to the ceuse(e) ateted. (Slgnamre and Title ) 9
<br />� � 1°
<br />r U O
<br />� 25. DIDTOB�EtO USE CO / UTETOTHE DEATH7 . 28a. HA9 ORaAN OR TIS3UE DONATION BEEN CONSIDERED7 28b. WA3 CONSENT ORANTED7
<br />❑ YES ❑ NO ❑ PFOBABLY D� UNKNOWN ❑ YES Q'(JO Not AppHcable if 28e le NO ❑ YES ❑ NO
<br />' 27.NAME,TITLEANDADDRESSOFCEH'fIFlER (PHYSICIAN,CORONER'SPHY6ICIANORCOUNTYAl70RNE1� (rypeorPdnt)
<br />Jane McDonald M.D. 800 Alpha Ave. Gran�i Island, NF. 68803
<br />28a.RE013TRAR'SSIONATURE � 28b. DATE FILED BY REaISTRAR (Mo., Dey,Yr.)
<br />' �• JAN 1 9 2005
<br />
|