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1. DECEDENTS -NAME (First, :.. Middle, Last, StASs) 2 2. SEX 3 3. DATE OF DEATH (Mo.,Day,Yr.) 4. CITY. AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF Berm S Sa AGE-Last Birthday M Mb. UNDER 1 YEAR l lie. UNDER 1 DAY I IL DATE OF BIRTH (Mo., Day, Yr.) MOS. D DAYS H HOURS . : : MINS. 7. SOCIAL SECURITY NUMBER M M. PLACE OF DEATH 58. FACILITY- NAME. (If not Institution, give street and number) 0 Grand Island 88803 1 H Hall w. RE&DENCE4ITATE i ilb. COUNTY S Se. CITY OR TOWN ed. STREET AND NUNBER 5 5s. APT. NO. M M. MP CODE I Ig. NMDE CITY LIMITS 10a. MARITAL STATUS AT TIME OF DEATH ❑Manlad ❑ Never M_..•�� 1 101s. NAME OF SPOUSE (Find, Middle, Wt, Suns) B vele,.givs middennates. 11. FATHER'S-NAME (Flat. Middle , Last, Sunni 1 12. MOTHER'S -NAME (FI 4 IRWIN, Medan Surname) 13. EVER IN U.S ARMED FORCES? 01w dais* of gawks If 1 141. INFORMANT -NAME 1 14b. RELATIONSHIP TO DECEDENT " 15. METHOD OF DISPOSITION 1 111a. EMBALM ER TTURE 1 10b. UCE E 110. 1 10o. DATE (Mo, Day. Yr.) 13d. CEMETERY. CREMATORY LOCATION CITY/TOWN STATE Cedarview Cemetery Doniphan Nebraska 17.. FUNERAL HOME NAME AND MAULING ADDRESS (Street. City or Town, Mato) 1 17b. Zip Code CAUSE OF DEATH (See Instructions and examples) 1t. PAOT 1. sewn. La41JYela - deeee . aeulea. or eo pI. td mode 00 NOT.eeriwalealweds ewe se melee .o.M. ' APPROXIMATE INTERVAL o.$'Mwy.nut.or.Mldeder11N Uo.. . .01 Nereid' Ike etiology. 00 NOTASM8VMTe Enter . Mien. w. an .wr.Add .soalrl 5w I l.euny. , IMMEDMTECAUSE: i onset todeath IMMEDIATE CAUSE (Fk1U � i dlewe condition resulting •) tic tfl) \,t. t . \t3 \ V.ct le dqM Sequentially S DUE OR AS A CONSEQUENCE OF onset to death an tits a DUE TO, OR AS A CONSEQUENCE OF.:. j Genet to damn Einar di. UNDERLYING CAUSE a P . .�` �` M g M Q 15. PART L OTHER SIGNIFICANT:CONDIHONS- Condltiane conbibunng to the death but not resulting In the underlying e.u. van In PART I. 1 15. WAS NEDICAL WMI/IER OR CORONER CONTACTED? ❑ YEs ;I(NO 20. M. FEMALE: 2 21a. MANNER OF DEAT14 2 210. IF TRANSPORTATION: 2 21c. WAS AN AUTOPSY PERFORMED? 21iLWERE AUTOPSY RN08405 AVAILABLE 22a. DATE OF INJURY (Mo., Day, Yr.) 2 22b. TIME OF INJURY 2 22e. PLACE OF INJURY -At home, term, stmt, fanny, epees building, consbuctIon DH., WI ( 8 0 0011 0 226 INJURY AT WORK? 2 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET • NURSER, APT. NO. CITY/TOWN STATE VP CODE � 2A. DATE: OF DEATH (M0., Day, Yr.);. 2 24a. DATE SIGNED (Ma, Dey. Yr.) 2 240. TIME OF:DEATIi Zee. PRONOUNCED DEAD (Mo.. Day. W-) 2 24d. TOSE PRONOUNCED DEAD 2 3b. DATE =RED (M0. D ay. ) 2 22e. TIME OF DEATH Z To be completed CORONER'S PHYS or COUNTY ATTOF ONLY 24e. On the beds /.m sinter si lea lion, In myopinion death oau 23d. To or my. , . diesel . at the Inn, date and plow -. 2 TOBACCO • - TE TO THE I IM. HAS ORGAN OR OOIIATION BEEN CONSIDERED? Y YID. WAS CONSENT GRANTED? 27. NAME. 7174E AND ADDRESS OF CERTIFIER (PHYSICIAN. PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY)Rype o or Print) py 25a • N N S WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH A1(S PS•NAfAN't THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIfAk RECORDS. DATE OF ISSUANCE 07/02/2012 LINCOLN, NEBRASKA STATE OF NEBRASKA ST4WLEY S COOPER , ,', ASSISTANT TAE REGISTRAR DEISMRTMEN''O HEAZT1 ;r HUMA&1 SERVICES : " rays or '-.` • E # firl > ` STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES � 8 2 CER1'IFi�ATE OF DEATH v 2 01210872 VICES, IT CERTIFIES EALTH AND