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1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Carolyn Anne Walker *fi 2, SEX Female 3, DATE OF DEATH (Mo., Day, Yr.) April 23, 2007 1 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Cedar Rapids, Nebraska 5a. AGE•Last Birthday (Yrs.) 63 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) MOS. DAYS HOURS MINS. August 18, 1943 7, SOCIAL SECURITY NUMBER 508 -54 -5798 8a. PLACE OF DEATH HOSPITAL: MInpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ m% ❑ Other(Specify) 8b. FACILITY -NAME (If not institution, give street and number) x'1 Saint Francis Medical Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island, 68803 8d. COUNTY OF DEATH Hall t) `, 9a. RESIDENCE -STATE Nebraska 95. COUNTY Hall 9c. CITY ORTOWN Grand Island 9d. STREET AND NUMBER 618 W. 11th 9e, APT. NO 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS M YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH XMarried ❑Never Mewled a '+; ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown tOb. NAME OF SPOUSE (First, Middle, Last, Suffix) It wife, give maiden name. Frederick G. Walker 11. FATHER'S -NAME (First, Middle, John J. Steffes 13. EVER IN U.S. ARMED FORCES? Give dates of service If yes. (Yes, no, or unk.) No Last, Suffix) 14a. INFORMANT -NAME Frederick G. 12. MOTHER'S -NAME (First, Middle, Ona Blanche Walker Maiden Surname) Lowe 14b. RELATIONSHIP TO DECEDENT Husband ■; 1S METHOD OF DISPOSITION N.BUrlal ❑ Donation a tl ❑ Cremation 0 Entombment ❑Removal ❑ Other (Specify) 16a.EM,A;,�MERR-- SIIGNATURE /� ,�.Gr�,/�/� e '/ C t . `) ,�i L,� (� �,,,8" 16b. LICENSE N0, 1092 16c. DATE (Mo., Day, Yr. ) Apr 26, 2007 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island NE 17e, FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, State) 117b, Zip Code +`r4 Curran Funeral Chapel 3005 South Locust Street , Grand Island, NE 68801 M1 18. PART I. Enter the chain of events - diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. i IMMEDIAT CAUSE onset to death I - . X a IMMEDIATE CAUSE (Final (a) "l L� A - F•'il- 'L,'�-.'(` a•W� 0" -N - A i �--G-Y, -� I .3 (T--C � . .✓ --- diseaseornondltion resulting DUE TO, OR AS A CONSEQUENCE OF: ` 0" I onset to death In death) v - §fi Sequentially list conditions, If ( any, lead to the cause listed DUE TO, OR AS A CONSEQUENCE OF: onset to death leading t( " online a. Eh y: xr, Enter the UNDERLYING CAUSE tai I$ i (disease or Injury that initiated (c) the eventa resulting indeath) . DUE TO, ORASA CONSEQUENCE OF: onset to death x:« LAST , ( {T S3 I c�' 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. „� 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES DI NO sr y'$ p. IF FEMALE: 1 / Y .. ' Not pregnant within past year ty( .}. °, ❑ Pregnant at time of death t 1 " ❑ Not pregnant, but pregnant within 42 days of death a7 +' ^:^ ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown it pregnant withis the paatyear 21a. MANNER OF DEATH XNatural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21 b. IFTRANSPORTATION INJURY ❑ Driver /Operator ❑Passenger. ❑Pedestilan ❑Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES al NO 21d. WERE AUTOPSY FINDINGS AVAILABLETO COMPLETE CAUSE OF DEATH? 0 YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22c. PLACE OF INJURY -Al home, farm, street, factory, office building, construction site, etc. (Specify) 220, INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 221. LOCATION OF mum - STREET 8 NUMBER, APT. NO. CRY/TOWN STATE ZIP CODE DATE OF DEAT (Mo , Y ) a. ., Day, <W = .1 c o Y w z o 2 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIME OF DEATH m ED DEAD Mo Da) 24c. PRONOUNCED (Mo., y, Yr.) TIME PRONOUNCED DEAD m 24d ' d r I n �, �b. DATE SIGN, D Mo., Day, Yr) , rno � I 7 / O7 23c.TIME OF DEATH c5 I m _� 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title ) e . u c d. To the best if my '5 owledge, death occur ed at the time, date and place o 7 and due to the E,8 e(s) slate (Sig e and Title ) T DID TOBACCO USE CONTRIB ETO THE DEATH? P y 0 YES ❑ NO XPROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSIJE DONATION BEEN CONSIDEAED? 0 YES X NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑YES X NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER ( PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Gordon J. Hrnicek M.D. 729 N. C'tusterAV. Grand Island, NE 68803 4 + 28a. REGISTRAR'S SIGNATURE ' c% 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) APR 3 0 2007 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEC TION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE MAY 0 2 200? 4INCOLN, NEBRASKA 201209847 EATH v STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUP TANLEY S. COOPER_: ASSISTANT _STATE REGISTRAR HEALTH-AND SERVICES_ 7 24758