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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND.F'WMAIII SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA,DEPARTMENT OFHEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR. VITAL RECORDS:
<br />•
<br />DATE OF ISSUANCE
<br />01/22/2013
<br />LINCOLN, NEBRASKA
<br />1, DECEDENT'S-NAME (First, Middle, Last,
<br />Linda L. Massing
<br />4. CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />Des Moines, Iowa
<br />7. SOCIAL SECURITY NUMBER
<br />506-42-4012
<br />fib.. FACILITY -NAME (II Rot '. institution. give street and number)
<br />2911 W. 17th
<br />Sc: CITY OR TOWN OF DEATH (Include Zip Cede)
<br />Grand Island
<br />Re.RESDSICE -STATE
<br />Nebraska
<br />2d.STREETA1 N(*lBER
<br />2911 W. 17th
<br />I So. MARITAL STATUS AT TIME OF DEATH ;. 01Merrlgd 0 Neve Named
<br />0 Married, but separated O Widowed 0 Divorced D Unlmow
<br />11: F ATHER'S -NAME
<br />Lee
<br />13. EVER
<br />(We.
<br />no, or
<br />IS. :METHOD OF DISPOSITION
<br />DDurhl ODonation '.
<br />Ckrumalon Q Entombme nt
<br />O R Smmml 0Other (Sootily)
<br />1WlDIATE CAME (fYMI
<br />Ogees eraorddtlmnhMnB
<br />NtNMId
<br />8eamn4MyEMoondRboeI
<br />usy.bedeploes molded
<br />online a.
<br />Er th.lNIOERLY180 CN11E
<br />(dimes orlattryther IMEered (W
<br />th 4 G' 4111114401 V41 1 . 044 0 :. DUE TO, OR AS A CONSEQUENCE OF
<br />28 IF FEMALE
<br />QE . Not Pregnant ' past year :: v
<br />0 Pregnant et time of death
<br />O NMpregnut. but pregnant within 42deysut death
<br />U Not preprint, but pregnant 42 days N I year Whore deelb
<br />Q Unknown if plasma whbIn Sr,paol you
<br />22a DATE OF INJURY (Mo., Da5,YL)
<br />22d. INJURY AT WORK?
<br />(] Yes CI NO a'.
<br />221. LOCATION: OF INJURY- STREETS NUMBER, APT. ND.
<br />2$a.: DATE OF DEATH (Mo., Deg Yr.)
<br />February 1. 2005
<br />23D DATE SIGNED (Mo., Day, Yr.)
<br />February 2,2005
<br />23d.To me bast d my knowledge, death occ
<br />to the came( n)s*ayE.IS
<br />28a REGISTRAR'S SIGNATURE
<br />STATE OF
<br />IMMEDIATE CAUSE:
<br />..
<br />G2
<br />DUE TO, OR AS A CONSEQUENCE OF
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF
<br />5)
<br />Ow. \ rz ov
<br />STATE OF NEBRASKA
<br />201300713
<br />BRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT GG
<br />CERTIFICATE OF DEATH O J
<br />68803
<br />%COUNTY
<br />Hall
<br />1Sa EMBALMER-SIGNATURE
<br />Not Embalmed
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />225. TIME OF INJURY
<br />m
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />21LMANNEROF DEATH
<br />a Natural UHorWdde
<br />L] Amiklent0 Pending lrrveabgarion
<br />()Suicide 0 Could nil .bedSIsnnbed
<br />CITY/TO/RI
<br />23c.TIME OF DEATH
<br />7:30 r pm
<br />a
<br />sr tar time, date and pleas
<br />'mantis)
<br />Bs. AGE-Last Birthday
<br />(Yrs-)
<br />66
<br />s
<br />Bronx)
<br />Bb. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />as. OF DEATH
<br />NOEIffAL: . D Inpal.ut
<br />Q ER/Outpatient
<br />Q
<br />Sc. CIYORTOWN
<br />Grand Island
<br />Be. : AFT. NO
<br />186. NAME OF SPOUSE (First, MIddk, Last, SWIM)
<br />Fred L. Massing
<br />(First, `. Middle, : Last, Suffix) : 12. MOTHER'S -NAME '.(First,
<br />A. Robertson Daisy
<br />IN U.S. ARMED FORCES/ Give datesd service H yes. 14s, INFORMANT-NAME
<br />. ) No Fred L. Massing
<br />Central Nebraska Cremation Service
<br />17a FUNERAL HOME NAME ANDMANJNG ADDRESS (Street, ova, State)
<br />Curran Funeral Cha•el 3005 South Locust St.s Grand Island,
<br />1 SIGNIFICANT CONDITIONS- Condition, contributing to the death but net reeultbi bribe sr teOO %esces
<br />1t
<br />tab. LICENSE NO.
<br />STANLEY S. COOPER -
<br />ASSISTA It �'Alik'
<br />DERARTME -e9F PIE L'FH AND ;J
<br />HUN,t4N SERVICES
<br />E. SEX
<br />Female
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />CITY ITOWN
<br />'
<br />wen* PART I.
<br />21b.IFTRANBPORTATION INJURY
<br />❑ DrMx/Cpardor
<br />O Paremger
<br />O Pedestrian
<br />Q Outer (Specify)
<br />24$. DATE SIGNED (Ma, Dey, Yr.)
<br />24c. PRONOUNCED DEAD IMO, OWN
<br />SOUNDER 1 DAY
<br />HOURS MINE
<br />Of. ZIP CODE
<br />68803
<br />wile give midden name.
<br />Middle,
<br />Gibbon,
<br />18 PART I. Enter the mist, of a eoi--diseases, blurts., or oompllcalmM- •Ihatdiredly cruised the death DO NOT enter tannins! wants such as arAac arrest,
<br />re rawly arrest, or ventricular Tbrdlaoon *Maul showing the etiology DO NOT ABBREVIATE. Baler only one cause on a line. Add additional SAN It neceseery.
<br />Nebraska
<br />25.OIDTOBA000� CONTRIBUTE TO e DEATH? . HAS ORGAN OR TISSUE DONATION SEEN CONSIDERED?
<br />0
<br />3 YES 0 PROBABLY 0 UNKNOWN O YES 41 NO
<br />27. NAME. TITLE AN DRESS OFC RTIFIER ER CIAN COUNTY TTORNE) PM*
<br />Ryan D. Crouch M. 8 N A l p ha st. Gran ' i sl and, Nebraska 68803
<br />22c. PLACE OF INJURY -AI home, Norm, sheet. taclary, dike building, construed ion site, Mc.(Specity)
<br />21a.TNAE OF DEATH
<br />2Bp. DATE FILED BY REGISTRAR
<br />1 -
<br />S. DATE OF DEATH (Ma, Def Yr.)
<br />February 1, 2005
<br />B, DATE OF BIRTH (Ma, DITTO
<br />November 30, 1938
<br />Mg Lite edng llbmwtTO Q Healed EWEr
<br />)1I De sdtifsHome
<br />AI E.(Spedt)___ Boise
<br />Mdden Surname
<br />Dixon
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />f 8e. DATE(Ma, Day, Yr.)
<br />Feb. 2,
<br />2005
<br />Nebraska
<br />lb. Zip Cods
<br />APPROXIMATE INTEINAL
<br />otrd le 0Mlh
<br />ones, to death
<br />onset* daet h >.
<br />01138
<br />1p. INSIDE CITY WAITS
<br />Y1 YES ONO
<br />68801
<br />Ie. WASImoCAL
<br />OR CORONER CONTACTED?
<br />O YES( 1I NO
<br />21a WAS AN AUTOPSY PERFORMED?
<br />DIMES LNO
<br />lid-WERE AUTOPSY FNDRpSAYARABI .ETD
<br />COMPLETE CAUSEOFDFARM
<br />G) ves O No
<br />24d. TIME PRONOUNCED DEAD
<br />4e. On the bus of examination =For inveeilgatin, N my opinion death occurred f
<br />IN lime, dare and place and due by the ousels) stated. (Signature and TIM ) V
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable 1128a M NO ' Q YES
<br />FEB 7 2005
<br />m
<br />.1/14A ThI
<br />HHS.e111/03 (66061)
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