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S7ATE OF NEBRASKA
<br />�
<br />. WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HE
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAZ RECORD ON FILE WITH THE NE82
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSTTOR;Y FO��
<br />i.
<br />DATE OF ISSUANCE
<br />07/26/2010
<br />LINCOLN, NEBRASKA
<br />Amended
<br />�01�0862G ��
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERI/ICES: r
<br />�. �+� `�.'��
<br />111 UNl IT CERTIFIES
<br />'EP�YIy'CAI,� �F} / IEALTH AND
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<br />Ct90PFR� . � n ,�'
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<br />�Z'E�R--DIST.ltAR� �;'
<br />'T OF HEALTH A�(,� � '
<br />:VI � � �•; �`•' „y :� `
<br />...... • '..�`� �: 10 01582
<br />ctrc i iricw� t vr ur�►i M �,� �•,� r i�} ., �-
<br />1. pECEDENTS-NAME (Flrst, Mlddle, Last, Suffbc) 2. SDC �� .° 3. DO�TE. QSD�ATH (Mo.,. Day, Yr.)
<br />�Vlarjorie Anna Slemon Female �June 7, 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Blrthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (MO., Day, Yr.)
<br />(Y►s•I MOS. DAYS HOUR3 MINS.
<br />Leavenworth, Kansas 92 October 4, 1917
<br />7. SOCIAL SECURITY NUMBER ' 8a. PLACE OF DEATH
<br />� 510 - 05 - 8620 HOSPI7 � InpaUer�t OTHER � Nuraing Home/LTC � Hospice Facllity
<br />8b: FACILIT'Y•NAME (If not IretlWtlon, gNe street arM number) ❑ ER/OutpaUerR ❑ Decede�R's Home
<br />�
<br />� !Lakeview-A Golden Living Center ❑ ooa ❑ oenar �speeKyr►
<br />� 8c. CITY OR TOWN OF DEATH pnclude ZIp Coda) 8d, COUNTY OF DEATH
<br />c Grand Island 68801 Hall
<br />� 9a; RESIDENCE-9TATE 8b. COUNTY 8c. CITY OR TOWN
<br />a Nebraska Hall Grand Island
<br />7� 8d: STREET AND NUMBER 8e. APT. NO. 8L ZIP CODE 9g. INSIDE CITY LIIWTS
<br />T 237 S. Sycamore 68801 � v�s ❑ No
<br />� 1Q8. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Marrled 10b. NAME OF SPOUSE (Firat, Mlddle, Last, Suffbc) If wife, give malden rmme
<br />� p nnamed but aeparated � usndowed ❑ Dhareed ❑ unicrrown Leonard Francis Siemon
<br />m
<br />� 11'; FATHER'S•NAME (Firat, Mlddie, Lasq Suffbc) 12. MOTHER'S-NAME (Ftret, Middle, 141�Iden Sumame)
<br />m Vlctor Wentzel Louise Eckert
<br />°' 13� EVER IN U.S. ARMED FORCES? Gfve dates W sarvice H Yes. 14a. INF(�RNWNT•NAME 74b. RELATIONSHIP TO DECEDENT
<br />E
<br />s 'j�ves, No, or unk.) No Karl �lemon Son
<br />,� 15; METHOD OF DISPOSITION 18a. EMBALMERSIONATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />� i p suriai p oo�non Not Embalmed June 8, 2010
<br />� CremaUon 0 ErKOmbment 18d. CEMETERY, CREMATORY OR OtHER LOCATION CffY / TOWN STATE
<br />�] Removal ❑ Other (Speefty)
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND NWILINO ADDRESS (Street, City or Town, State) 17b. Zlp Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See instructlons and exam les
<br />18. �PART L EMer the chaln oTeve��dlseasee, InJurles, or compilcatlonsdhat diracUy cauaed the death. DO NOT eMazterminal eveme euch as cardlac arresi, ; APPROXIMATE INTERVAL
<br />� resplramry erteat, or vaMriwlar flbNllatlon without ehowing the etlology. 00 NOT ABBREVIATE EMer ony one cause on a Il�re. AtlA addi8crtal Wres H�.
<br />IMMEDIATE CAUSE: ; orreet to death
<br />memmwrecause��� 0)Respiratory Failure 6 One Week
<br />dlsea� or eondidon resulUng
<br />1° d � ' � DUE TO, OR AS A CONSE4UENCE OF: ; oreet to death
<br />Seque�rtlalry Iist conditlona, M b) Malnutrltion,dehydraUon,hypematretnia ; Months
<br />aRy. leading to the cause Ilsted
<br />'n � e � DUE TO, OR AS A CONSEQUENCE OF: � onaet W death
<br />�ner�ne uNU�nnto cause �1 Aged, Peripheral Vascular Disease 6 Years
<br />(dleease m InJury thst Initlated
<br />�� "�'�°�"e �" d�'� DUE TO, OR AS A CONSEQUENCE OF: � = onset M death
<br />d)
<br />, �
<br />18: PART II.OTNER SIONIFlCANT CONDITIONS-CorMlUOrre conhibuting M the death but rrot resultlng In the u�eMying cause given in PART 1. 78. WAS MEDICAL EXAMINER
<br />C)iabetic, osteoporosis, stroke OR CORONER CONTACTED4
<br />� ❑ YES � NO
<br />W 20� IF FEMALE: 21a. MANNER OF'DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />�
<br />� .Q NotP�Bna�nwMhinpastl� � � Natural � Homlcide � DrivadOPerator � YES � NO
<br />� � PreBnant at tlma of death � Accident � PeiMIn9lnvestl9aUon ❑ P � O B�
<br />� [`] Not Dree�errt, but pregnam wlthin 4z daye ot death guiclde Coutd not be determined � PBdestria" 21 d. YYERE AUTOPSY FlNDINOS AVAILABLE
<br />' � Not pregnanf, 6ut pragnerrt 43 daye to 1 year betore deafh � � � p� �gp��y� TO COMPLETE CAUSE OF DEATH?
<br />� Q unlmown Ii pregna�rt within the past year ❑ YE$ ❑ NO
<br />m
<br />E 22A. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURY-At home, farm, street, faetory, office bWlding, consWeUon alte, etc. (Spacffy)
<br />s
<br />� 22d. INJURY AT WORK4 22e. DESCRIBE HOW INJURY OCCURRED
<br />o '
<br />F" ❑ YES ❑ NO
<br />22t. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />` 23a: D�iE OF DE�' 4TH (MO, Day� Yr.) _ � 24a. DATE SKiNED (Mo., Dap, fr.r -_ 24b:77�1Et�F CEATH-- _
<br />.� � June 7, 2010 .� �
<br />� y 23b. DATE SIONED (Mo., Day, Yr.) 23c. TIME OF DEATH ' �� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� � Z June 8, 2010 12:18 AM �
<br />$!� � . To tha best oi my Imowledga, tleatb ocwrred at the Ume, date and piace � $ R�� 24e, On the baels of e�mmination anNor Imestigatlon, in my opinlon death ocwrted ffi
<br />�� end due to the muse�s) effied. (Signature antl TWe) $ �� the dme� tlate antl Plaee am! due to thb cauae(s) etated. (Slgnature antl TIGa)
<br />~ Jane A. McDonald, MD '" $ ;
<br />25; DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORQAN OR TISSUE DONATION BEEN CONSIDERED9 28b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO NotApplleable H28a Is NO ❑ YES ❑ NO
<br />27. E, LE D AD O C R P IC , HYSICIAN TANT, C S S O COUN ORN (Type or P►irrt)
<br />Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE �- 28b. OATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />June 9, 2010
<br />ended
<br />7/28/2010 Item 8
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