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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN-�ERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGIIVAL RECORD ON FILE WITH THE NEBRASKA DEP;4RTMENT Of HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V1TAL�L�Ql�p y
<br />DATE OF ISSUANCE
<br />09/04/2012
<br />201207603
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN
<br />AIIG�EY.� � �
<br />'C.i - � = '�' � �. �.
<br />S��FA STATE REGIS�RARU , '��' . -
<br />�AfY7"MENT O� �EALTH AI1jDl ;�
<br />he1RN S�J817�CE� - �„ ,'
<br />��at � � � � . . „ s
<br />��E� ` 9 2 03164
<br />CERTIFICATE OF DEATH `, "','�. ,, " - :"_ � ,�
<br />7. DECEDENTS-NAME (Flrst, Mlddle, Last, SuHiz) 2. SEX '� �•. �,~ � D�A'�'(� Day. Yr.)
<br />LaVem Ray Fuller Mafe, ����r'•• ..August,�9ti2012
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last Blrthday b. UNDER 1 YEAR Sc. UND R41 DAY� 6: DA`�� OF BIRT-W (Mo, Day, Yr.)
<br />(Y►S•) MOS. DAYS HOURS NONS. ` -'
<br />Grand Island, Nebraska 91 May 17,1921
<br />7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />506 ��4 � InpaUeM OTHER ❑ Nursing Home/LTC � Hosplee Facilily
<br />8b. FACILI7'Y•NAME (H not I�t14Rion, glve street arM number) � ER/Outpadent ❑ DecedeM s Home
<br />�
<br />� Saint Francis Medical Center ❑ DOA ❑ Other (Specliy)
<br />�
<br />� 8c. CfTY OR TOWN OF DEATH (Include 2Ip Code) 8d. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 9a. RESIDENCESTATE 8b. COUNTY 9c. CITY OR TOWN
<br />Nebraska Hall Alda
<br />� 8d. STREET AND NUMBER e. APT. NO. 9f. ZIP CODE 8g. INSIDE CITY LIMITS
<br />�, 2280 South Engleman Road 68810 � r�s ❑ No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH � MarHed ❑ Never Marrled 10b. NAME OF SPOUSE (FUat, Mlddie, Last, SuffUc) N wRe, gtve maiden mame
<br />� ❑ ru�Maa but separated ❑ wiaow�a ❑ D(vorced ❑ u��ow� Eleanore Bruenecke
<br />d
<br />� 11. FATHER'S-NAME (First, Middle, Laet, SuHix) 12. MOTHER'3-NAME (Firat, Mlddie, Malden Sumame)
<br />Floyd T Fuller Viva E Crouch
<br />°' 13. EVER IN U.S. ARMED FORCEST GWe datea of service HYea. 14a. INFORMANT-NAME 74b. RELATIONSHIP TO DECEDENT
<br />s (Yes, No, orun�c.) Yes 12/09/1941-11/08/1945 Eleanore Fuller Spouse
<br />� 18. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F � B"h''� ❑ o°"aN°n Derek Apfel 1240 August 27, 2012
<br />❑ Cre�Uon ❑ Entombmerrt 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />� Remrnral ❑ ocner �spec�ry� Grand Island Ciiy Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, CHy or Town, Stete) 17b. ZIp Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See Instructions and exam les
<br />1& PART t. EMer the shaln oi eveirte-dlseases, iryuriea, or compoeatlonsdhet dlrectiy caused fhe death. DO NOT eMer terminal eve� sucb ae carAlac arrest, ; APPROXIMATE INTERVAL
<br />reapiratory artest, or verrtrieular fl6d11aUOn wkhout showinp fhe etlology. DO NOT ABBREVIATE. Fster onry o�re muse on a U�re. Add eddMOnat Mea H neceseary.
<br />IMMEDIATE CAUSE: � onset to death
<br />u�uxeowre cause � a) Respiratory Failure ; Immediate
<br />uiseaee or condmon resuuing
<br />��) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />s��emun, b)Myocardlal Infarctlon 9 2 Day
<br />arry. leatling to the muse Iisted
<br />���� e � DUE TO, OR AS A CONSEQUENCE OF:
<br />p on.aet to death
<br />��� uNOEw.rwo c�wse c) Congestive Heart Failure Sec�nday To Mycardial Infarctlon ; 2 Day
<br />(disease or InJury that Intdated
<br />��"� � �^ d �'� DUE TO, OR AS A CONSEQUENCE OF: : o�et to death
<br />LNSr d� �
<br />18. PART il. OTHER SIGNIFlCANT CONDITIONS�Condido�re coMributt� to tFre death but not �ulUng in the u�derryi� eause given In PART 1. 19. WAS MEDICAL EXANUNER
<br />OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />W O. IF FEMALE: 2�a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />� � Not Pre9�M wlthin pastyear � Natural � Homielde � DrivedOperetor ��S � NO
<br />� � PreBnant ffi tl� of death � Acclde�R � Pendln9 InveatlB�on ❑ PaeeenBer
<br />� � Not pregnaM, but pragna�rt within 42 daye oi tleatFi � Pedeatrlan 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />� swdde � couta na ne aeeermined TO COMPLETE CAUSE OF DEATHT
<br />� Not PreB�. but PreBnaM 43 days ro 1 Y�r beTore death � Other (SDecHY)
<br />� � un�mown rc pregna�rt wnnm the past y�r ❑ 1IE9 ❑ NO
<br />a 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, oftice buUding, co�tructlon site, etc. (Speclfy)
<br />E
<br />$
<br />� 22d. INJURY AT WORK1 22e. DESCRIBE HOW INJURY OCCURRED
<br />F�
<br />❑ YES ❑ NO
<br />22f. LOGATION OF INJURY • STREET & NUMBER, APT.NO. CITYlfOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) � 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />S August 23, 2012 S�
<br />��� 23b. DATE SIGNED (Mo., Day, Yr.) 23e. TIME OF DEATH �°� � y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />$$ Z Au ust 30, 2012 12:50 AM g�` < z
<br />�+ � 0 . To fhe best of mY Imowted9e. death occurred at tire 8�� date entl place $��Z � 24e. On the basie ol e�mminadon and/or ImesdBatlo4 In mY aPlnion death ocwrted at
<br />�� ena aue w nre wusecs) arama. �s�gnawre end rwe� 8�$ tne eme. aam a�ro Waae ana aue m u,a cauee(s) amma. (srenamre s�,a rme)
<br />~ Michael A. Donner, MD ~ g�
<br />28. DID TOBACGO USE CONTRIBUTE TO THE DEATH? 28a. H/6S ORGAN OR TISSUE DONATION BEEN CONSIDERED4 28b. WAS CONSENT GRANTEDI
<br />❑ YES � NO ❑ PROBABLY � UNlWOWN ❑ YES � NO Not AppUeable B 28a Is NO ❑ YES ❑ NO
<br />2. NAME, TI LE D ADDR C R FIER (Type or PrhR
<br />Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28�. REGISTRAR'9 SIGNATURE �+ ZBb. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />August 30, 2012
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