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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 SECTION„. WHICH I$,., THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE MAR 0 7 2006 LINCOLN, NEBRASKA 201306136 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES - FINANCE AND SFJFPORT CERTIFICATE OF DEATH 6 2 3 05 ANLEY S. c126 PER ASSISTANT STATE REGISTRAR HEALTH AND HUMAN SERVICES /`. 1. UtGtutN FS (First, Middle, Last, Suffix) Ric Wa Marsh 2. SEX Mal 3. DATE OF DEATH (Mo., Day, Yr.) F r 1aT 28 006 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Doniphan, Nebraska 5a. AGE -Last Birthday (Yrs.) ggqq 5b. UNDER 1 YEAR 5c. UNDER I DAY y , 6. DATE OF BIRTH (Mo., Day, Yr.) April 21, 1916 MOS. DAYS HOURS MINS. (32. 7. SOCIAL SECURITY NUMBER 507 -03 -7430 8a. PLACE OF DEATH HOSPITAL: ❑ Inpatient OTHER • )NursingHome /LTC U Hospice Facility Home (Specify) 8b. FACILITY -NAME (It not Institution, give street and number) Grand Island Veterans Hane 2300 W. Capital Avenue CJ ER/Outpatient ❑Decedent's ❑ CON ❑ Other 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island, Nebraska 68803 8d. COUNTY OF DEATH Hall County 1 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d.5TREETANDNUMBER 2300 W. Capital Ave. 9e. APT. NO 9t. ZIP CODE 68803 9g. INSIDE CITY LIMITS A YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated X] Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. = 11. FATHER'S -NAME (First, Middle, Last, Suffix) Richard Marsh 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Addie Cleal 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. (Yes, no, orunlr9 /22/1945 4/24/1946 14a. INFORMANT-NAME nay A MarAll 14b. RELATIONSHIP TO DECEDENT Son 15. METHOD OF DISPOSITION CBurlal ❑Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) �''�''��gee"--"11 165. EMBALr�cn -trlG 16b. LICE I / .� 5 E E N . �s, /,{ ! 16c. DATE (Mo., Day, Yr. ) March 4, 2006 18d. CEMETERY, CREMATO Y OR OTHER LOCATION CITY / TOWN Cedarview Cemetery Doniphan P STATE Nebraska 17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, State) Apfel Funeral Home 1123 West 2nd Street Grand Island, Nebraska 1"t 18. PART L Enter the chainol v nt. -- � diseases, injuries, or complications- -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. - "T IMMEDIATE CAUSE: I onset IMMEDIATE CAUSE (Final (a) Acute Myocardial Event disease or condition 15 I7b. Zip Code 68801 INTERVAL to death Minutes resulting DUE TO, OR AS A CONSEQUENCE OF: in death) onset to death Sequentially llst conditions, if b CAD with ischemic cardianyopathy _ >1 Year any, leading to the cause listed DUE TO, OR ASACONSEQUENCEOF: ,:. on line e. I onset to death Enter the UNDERLYING CAUSE (disease or Injury that Initiated (c) Congestive Heart Failure fi the events resulting in death) >1 Year DUE TO, OR AS A CONSEQUENCE OF: LAS onset to death (d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. CIO , D 2 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ 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 latural ❑ Homicide ❑ Accident❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21 b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑Passenger ❑Pedestrian ❑Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ANO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 'm 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 221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN Suut ZIP CODE A S j o _ > E a i 8 c_0 235. DATE OF DEATH (Mo., Day, Yr.) February 28, 2006 ,, w aU Z ' _ as 4 E2� 24a. DATE SIGNED (MO., Day, Yr.) Da Y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24b. TIME E OF DEATH m 24d. TIME PRONOUNCED DEAD m 23b. DATE SIGNED (Mo., Day, Yr.) February 28, 2006 23c.TIME OF DEATH 3:35 A. m 23d. v . To the best of my knowledge, death occur ed at the time, date and place and due to the cause(s) stated. (Si ature and Title) • ' Q yy, ,/� w z 24e. On the basis of examination and/or investigation, 2 Z gallon, in my opinion death occurred at o ¢ v t he time, date and place and due to the cause(s) stated. (Signature and Title) • ~ c 25. DID TOBACCO USE CONTRIBUTE TO THE D TN? ❑ YES MO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES l' NO 26b. WAS CONSENT GRANTED? NotApplicebleif26aisN0 ❑YES ❑NO OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) M.A. Tarlpkins, M.D., Grand Island Veterans Hane, Grand Island, NE 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I MAR 6 2006 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 SECTION„. WHICH I$,., THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE MAR 0 7 2006 LINCOLN, NEBRASKA 201306136 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES - FINANCE AND SFJFPORT CERTIFICATE OF DEATH 6 2 3 05 ANLEY S. c126 PER ASSISTANT STATE REGISTRAR HEALTH AND HUMAN SERVICES /`.