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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH+ANb ERVICEE, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR.UKA QEPARTMENT OF: HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL 2EC S , DATE OF ISSUANCE 11/08/2012 201301719 STANLEY P R • ° ", jGIS7AR DEP; ATM T H AL i ri Al LINCOLN, NEBRASKA Hf,IM>4(U SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES ' J . < F' r 12 04148 CERTIFICATE OF DEATH 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Kenneth Hamilton Elson 2. SEX ' , a Male '3. DATE'OF,p,EATH (Mo., Day, Yr.) NOVai fiber 3, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Maywood, Nebraska 5a. AGE - Last Birthday (Yrs.) 90 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) April 26, 1922 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -12 -1494 8b. FACILITY -NAME (If not Institution, give street and number) 1531 Stagecoach Road 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1531 Stagecoach Road 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Josephine Duering 11. FATHER'S -NAME (First, Middle, Last, Suffix) C R Elson 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Clara Hamilton 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 05/18/1944- 09/13/1946 14a. INFORMANT -NAME Josephine Elson 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) November 5, 2012 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART L 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 onset to death Immediate respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Natural Causes Associated With Old Age disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: . onset to death Sequentially list condition, if b) any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE C) (disease or Injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART 1. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of de ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver/operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 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) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE W i E. y E Z 23a. DATE OF DEATH (Mo., Day, Yr.) r ; a E i E Y E ° $ N W O 2 C p i 0 s 24a. DATE SIGNED (Mo., Day, Yr.) November 5, 2012 24b. TIME OF DEATH Approx. 03:20 PM 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) November 3, 2012 24d. TIME PRONOUNCED DEAD 03:39 PM J s U < 0 9tl. To the best of my knowledge, death occurred at the time, date and place 2 c and due to the cause(s) stated. (Signature and Title) 1 l 24e. On the basis of examination amllor Investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Martin Klein, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER(Type or Print Martin Klein, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 128a. REGISTRAR'S SIGNATURE /]tom � � �� _ /�� -• - �J V 26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I November 6, 2012 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH+ANb ERVICEE, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR.UKA QEPARTMENT OF: HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL 2EC S , DATE OF ISSUANCE 11/08/2012 201301719 STANLEY P R • ° ", jGIS7AR DEP; ATM T H AL i ri Al LINCOLN, NEBRASKA Hf,IM>4(U SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES ' J . < F' r 12 04148 CERTIFICATE OF DEATH