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STATE OF NEBRASKA �Q i �Q 1219
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HE T AN. H MAN SERVICES,IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br /> DATE OF ISSUANCE
<br /> 12 STANLEY S. COOPER-
<br /> 07/02/20 ,`, •
<br /> ASSISTANT •
<br /> f T £ EGI$TRAR "
<br /> DEPARTM.ENTt lEAATH AND
<br /> LINCOLN, NEBRASKA HUMAN$ERVICES
<br /> STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICES' n '- '"4 , , 12 02317
<br /> CERTIFICATE OF DEATH '{.; .: .
<br /> -1.DECEDENT'S-NAME (First, Middle, Last, Suffix) 2.SEX ° , 3.DATE OF DEATH(Mo.,Day,Yr.)
<br /> Donald Lee Bannister Male June 23,2012
<br /> 4.CITY AND STATE OR TERRITORY,OR FOREIGN COUNTRY OF BIRTH 5a.AGE-Last Birthday b.UNDER 1 YEAR 5c.UNDER 1 DAY 6.DATE OF BIRTH(Mo.,Day,Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br /> Monroe County,Missouri 74 I I January 3, 1938
<br /> 7.SOCIAL SECURITY NUMBER 8a.PLACE OF DEATH
<br /> 494-40-2589 HOSPITAL ❑Inpatient OTHER ❑Nursing Home/LTC ❑Hospice Facility
<br /> 8b.FACILITY-NAME(If not Institution,give street and number) ❑ER/Outpatient ®Decedent's Home
<br /> re
<br /> 224 Wainwright Street ❑DOA ❑Other(Specify)
<br /> K 8c.CITY OR TOWN OF DEATH(Include Zip Code) I8d.COUNTY OF DEATH
<br /> o Grand Island 68801 Hall
<br /> J 9a.RESIDENCESTATE 9b.COUNTY 9c.CITY OR TOWN
<br /> Nebraska I Hall I Grand Island
<br /> LL9d.STREET AND NUMBER I9e.APT.NO. 9f.ZIP CODE 9g.INSIDE CITY LIMITS
<br /> T 224 Wainwright Street I 9f 68801 I ® YES ❑ NO
<br /> 1 10a.MARITAL STATUS AT TIME OF DEATH®Married ❑Never Married 10b.NAME OF SPOUSE(First, Middle, Last, Suffix)If wife,give maiden name
<br /> !E ❑Married,but separated ❑Widowed ❑Divorced ❑Unknown Trina L Garrett
<br /> 11.FATHER'S-NAME (First, Middle, Last, Suffix) 12.MOTHER'S-NAME (First, Middle, Maiden Surname)
<br /> d Gill J Bannister Artie E Huffman
<br /> E 13.EVER IN U.S.ARMED FORCES? Give dates of service if Yes. 14a.INFORMANT-NAME 14b.RELATIONSHIP TO DECEDENT
<br /> 8 (Yes,No,or Link.)No Trina L Bannister Spouse
<br /> 15.METHOD OF DISPOSITION 16a.EMBALMER-SIGNATURE 16b.LICENSE NO. 16c.DATE(Mo.,Day,Yr.)
<br /> FO„ ❑Burial ❑Donation
<br /> Tracey Dietz 1328 June 27,2012
<br /> ®Cremation 0 Entombment 16d.CEMETERY,CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br /> ❑Removal ❑Other(Specify)
<br /> Central Nebraska Cremation Services Gibbon Nebraska
<br /> 17a.FUNERAL HOME NAME AND MAILING ADDRESS(Street,City or Town,State) 17b.Zip Code
<br /> Apfel Funeral Home, 1123 W.2nd,Grand Island,Nebraska 68801
<br /> CAUSE OF DEATH(See instructions and examples)
<br /> 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
<br /> respiratory arrest,or ventricular fibrillation without showing the etiology.DO NOT ABBREVIATE.Enter only one cause on a line.Add additional lines If necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE(Final a)Metastatic Renal Cell Cancer Kidney 5 Years
<br /> disease or condition resulting
<br /> I
<br /> In death) DUE TO,OR AS A CONSEQUENCE OF: onset to death
<br /> Sequentially list conditions,If b)Aortic Aneurysm 2 Years
<br /> any,leading to the cause listed
<br /> on line a. DUE TO,OR AS A CONSEQUENCE OF:
<br /> onset to death
<br /> Enter the UNDERLYING CAUSE c)
<br /> (disease or injury that Initiated
<br /> the events resulting in death) DUE TO,OR AS A CONSEQUENCE OF: onset to death
<br /> LAST d)
<br /> 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
<br /> OR CORONER CONTACTED?
<br /> ❑YES ®NO
<br /> re
<br /> W 20.IF FEMALE: 21a.MANNER OF DEATH 21b.IF TRANSPORTATION INJURY 21c.WAS AN AUTOPSY PERFORMED?
<br /> u.
<br /> i- ❑Not pregnant within past year ®Natural ❑Homicide ❑Driver/Operator ❑ YES ® NO
<br /> 0 Pregnant at time of death ❑Accident ❑Pending Investigation ❑Passenger
<br /> dT ❑Not pregnant,but pregnant within 42 days of death Could not be determined ❑Pedestrian 21d.WERE AUTOPSY FINDINGS AVAILABLE
<br /> v
<br /> ❑Not pregnant,but pregnant 49 days to 1 year before death ❑Suicide ❑ ❑Other(Specify) TO COMPLETE CAUSE OF DEATH?
<br /> 2 ❑Unknown if pregnant within the past year ❑ YES 0 NO
<br /> E 22a.DATE OF INJURY(Mo.,Day,Yr.) 22b.TIME OF INJURY 22c.PLACE OF INJURY-At home,farm,street,factory,office building,construction site,etc.(Specify)
<br /> 3
<br /> 2 22d.INJURY AT WORK? 22e.DESCRIBE HOW INJURY OCCURRED
<br /> ❑YES ❑NO
<br /> 22f.LOCATION OF INJURY-STREET&NUMBER,APT.NO. CITY/TOWN STATE ZIP CODE
<br /> 23a.DATE OF DEATH(Mo.,Day,Yr.) 24a.DATE SIGNED(Mo.,Day,Yr.) 24b.TIME OF DEATH
<br /> b'W June 23,2012 S g
<br /> F
<br /> i 23b.DATE SIGNED(Mo.,Day,Yr.) 23c.TIME OF DEATH 1 s'' 24c.PRONOUNCED DEAD(Mo.,Day,Yr.)24d.TIME PRONOUNCED DEAD
<br /> E u z June 25,2012 I 05:55 AM II<
<br /> 8 4 0 23d.To the best of my knowledge,death occurred at the time,date and place a z O 24e.On the basis of examination and/or Investigation,in my opinion death occurred at
<br /> 8 c and due to the cause(s)stated.(Signature and Title) 8 c0i the time,date and place and due to the cause(s)stated.(Signature and Title)
<br /> V William Lawton,MD ~u s
<br /> 25.DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a.HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? -26b.WAS CONSENT GRANTED?
<br /> ❑YES ®NO ❑PROBABLY ❑ UNKNOWN []YES ID NO 'Not Applicable if 26a Is NO ❑YES ❑NO
<br /> 27.NAME,TITLE AND ADDRESS OF CERTIFIER(PHYSICIAN, HYS''ICIAN ASSISTANT,CORONER'S PHYSICIAN OR COUNTY AtTTTORNEY)(Type or Print)
<br /> William Lawton, MD,2444 W. Faidley Avenue,Grand Island,Nebraska,68803
<br /> 28a.REGISTRAR'S SIGNATURE A. 11 28b.DATE FILED BY REGISTRAR(Mo.,Day,Yr.)
<br /> W�� June 29,2012
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