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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND.H6lNJA ,N,SERVICES, IT CERTIFIES
<br />THE BEtOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASK�1 DEPARTM�N�OE HE�lTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR IFFT,4� R� �l,?S ' ����
<br />DATE OF ISSUANCE � � ';l Y ,
<br />� • iJ l �-- v � ; .
<br />`� 0120 � 5 6 4 ST�N�S. � �� _: l , ;.
<br />06/1512011 �+ ASSIS'fA�NT�TA7'HR�'I�ISTRAR .� g;
<br />DEPAR�IfNT OF HEALTH AN� ,.; :
<br />LINCOLN, NEBRASKA HUA7AIV;5C�IfjCES ' ` � °°
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE3 L �' ' � �"' �' '`•� �' �'' , ° #` � " 4
<br />f'CCTICIf�ATC AC 1'►CATLJ �� ->��� ��990
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<br />1. DECEDENTS-NAME (First, Middle, Last, Suffbc) 2. SD( ' 3. qATE OF DFJtTH (Mo., Day, Yr.)
<br />Will-Llna Royse Female June 10, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREItiN COUNTRY OF BIRTH Sa. AGE • Last Birthday b. UNDER 1 YEAR Se. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(YB•) MOS. DAYS HOURS MINS.
<br />Amarillo, Texas 80 June 2, 1831
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />460-40-3365 HOSPITAL � Inpatle�U OTHE � Nursl� HomelLTC � Hoapiee Faeillty
<br />8b. FACILITY•NAME (H irot InstiWtlon, give atreet ami number) � ER/Outpaderrt ❑ Decedent's Home
<br />�
<br />� St. Francis Memorial Heaith Center LTC ❑�A ❑��($P�ffY)
<br />v
<br />� 8c. CITY OR TOWN OF DEATH pnclude Zip Code) 8d. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 8a. RESIDENCESTATE 9b. COUNTY 9c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />LL 8d. STREET AND NUMBER 9e. APT. NO. 8L LP CODE 9p. INSIDE CITY LIIVOTS
<br />�, 4721 Calvin Drive 68801 � v�s ❑ No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH � Married � Never Married 10b. NAME OF SPOUSE (First, Middle, Lask Sufflx) M wHe, give malden iwme
<br />� ❑ nnaMea but separated ❑ wnaowed ❑ onrorced ❑ unicnown George Thomas Royse
<br />� 11. FATHER'S-NAME (First, Mlddle, Last, Suff6c) 72. MOTHER'S�NAME (Ftrst, Mlddle, Matden Surname)
<br />m Malcom Henry Clack Will-Lina Shelton
<br />E 13. EVER IN U.S. ARMED FORCES? Give dates of service ff Yea. 14a. INFORMANT•NAME 74b. RELATIONSHIP TO DECEDENT
<br />� �res, No, or unk.� No George Thomas Royse Husband
<br />,$ 15. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. UCENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F ❑ Burial ❑ DonaUon
<br />Not Embalmed June 13, 2011
<br />� Crerr�Uon � ErKombmeot �gd. CEMETERY, CRENL4TORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Specify)
<br />Central Nebraska CremaUon Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND NWLING ADDRESS (Street, Cily or Town, Sfate) 17b. Zlp Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See nstructlons and exam les
<br />1& PART L Emerthe chain ot eveMS-�diseasee, injuriee, or compllcatlonrthat diraGry cauaed the death. DO N0T eMer terminal eve�rte such ae cardtac erte�, ' APPROIQMATE INTERVAL
<br />�piratory errest, or ve�rtriwlar fl6rUladon wtthout ehowlnB ��o�o9Y� DO NOT ABBREVIA7E. EMer anry o�re cauae on a Ihre. Add additlonal Iims M necaesary. �
<br />IMMEDIATE CAUSE: ; o�et M death
<br />�enne�uwre cause ��, a) MetastaUc Colon Cancer ; 14 Months
<br />dleease or conditlon resultlnp
<br />��� DUE TO, OR AS A CONSEQUENCE OF: ; oreet W death
<br />Seyue�a�y �iac conamo�re. rc b)
<br />a�ry. leatlinp to the cauee Ilstetl -
<br />on Ii�re a DUE TO, OR AS A CONSEQUENCE OF: � oreet to death
<br />�ncer me unwEm..rwo cwse �1
<br />m
<br />(atsea� or Injury that initlatetl
<br />the eve� reaWU� �n death) DUE TO, OR AS A CONSEQUENCE OF: : orreet to death
<br />usT d)
<br />78. PART Ii. OTHER SIGNIFlCANT CONDITIONS�Conditlore contributing W the death but not resuftlng In the underyi� eause given in PART L 18. WAS MEDICAL EXAMINER
<br />Diabetes, Atrial Fibrillation, Osteoarthritis Of The Lumbar Spine, Hypertension OR CORONER CONTACTED�
<br />� ❑ �s � No
<br />W 0. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED7
<br />� � Not prep�nt wMhin peat year � Netural � Homldtle � DriveqOperator
<br />W Prepnant at tlme ot tleath � P ��, ❑�S � NO
<br />V ❑ � Aecide�rt � Pending Inveatlpation
<br />� Na prepmnt, but pregnairt wtthln 42 daye oi death � Pedeatrian 27d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />'� � Dwt prepnam, but prepnant as daye to 7 year betore ueath ❑ guidue � Could not be determ�ned ❑ � r (g��� TO COMPLETE CAUSE OF DEATH?
<br />� ❑ Unimown Ii prepna�rt withln the peat year ❑ YES ❑ NO
<br />a 22a. DATE OF INJURY (MO., Day, Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURY-At home, farm, atreet, factory, oHiee butldl�, eorrebucdon aRe, ete. (Spectty)
<br />E
<br />s
<br />.S 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />� YES ❑ NO
<br />22t. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/fOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) � 24a. DATE S10NED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />S� June 10, 2011 B�
<br />E� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH � 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />Z June 13, 2011 03:40 PM �< Z
<br />8�� w. To tne beet or my w,ow�edee, dean, occurrea at trre ttme, date ana p�ace $��°
<br />and due to tire qu�(a) sfated (Slpnature arM Title) � 24e. On the baels M e�wminatlon anNor Imasdpadon. In my oPlnlon tleath occurted at
<br />i � !°- & V tho Uma. tlate and Place and due to ihe ceuaele) statetl. (316nature and Tltle)
<br />Kimberly A. Mickels, MD g 5
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. MAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY � UNKNOWN ❑ YES � NO Not Appllcable B 28a 18 NO � YES ❑ NO
<br />2. NAME, TITLE R IER (P Y 1 , Y 1 T, R P ICIAN N A E1� (Type or Pr nt)
<br />Klmberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REOISTRAR'S SIONATURE � 28b. DATE FlLED BY REGISTRAR (Mo, Day, Yr.)
<br />June 14, 2011
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