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STATE OF NEBRASKA
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT 1*HEALTP MN9'HUMAN SERVICES,IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITM:THE,WE'BRA$KA455RAFTMENT OF HEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY'EORiVIT,�r'T•RECQI/DS. '
<br /> . .,
<br /> DATE OF ISSUANCE .
<br /> r; '' ‘C115d2X4'
<br /> q {y `STA'NLEY S. COQa`�EF
<br /> MAY 0 2 0 10 201. 306768'
<br /> . f 4• '.ASSISTANT STATE REGISTRAR
<br /> DEPARTMENT OF.HBi.ALTH AND
<br /> LINCOLN, NEBRASKA ,\ ''. /.HUMAN SEtf2VICES
<br /> { `' L'• y,..;',
<br /> STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICES FIf1AP RNb SUPPORT-r
<br /> CERTIFICATE OF DEATH 11 23572
<br /> �, y 1.DECEDENT'S-NAME (First, Middle, Last, Suffix) 2.SEX 3.DATE OF DEATH(Mo.,Day,Yr.(
<br /> KayLvnn - Loveland Female April 28, 2010 -__
<br /> i
<br /> .;:,,_ a.CITY AND STATE OR TERRITORY,OR FOREIGN COUNTRY OF BIRTH Sa.AGE-Last Birthday 15b.UNDER 1 YEAR Sc.UNDER 1 DAY 6.DATE OF BIRTH(Mo.,Day,Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br /> Grand Island, Nebraska 57 September 15,1952
<br /> - 7.SOCIAL SECURITY NUMBER 8a.PLACE OF DEATH
<br /> =" 508-64-7937 HOSPITAL: ❑Inpatient CEI:EB: U Nursing Home/LTC U Hospice Facility •
<br /> F 8b.FACILITY-NAME (If not institution,give street and number)l ER/Outpatient ❑Decedent's Home
<br /> St. Francis Medical Center ❑ Mk ❑Other(Specibrl
<br /> '',: ec.CITY OR TOWN OF DEATH(Include Zip Code) 8d.COUNTY OF DEATH
<br /> Grand Island 68803 Hall
<br /> 9a.RESIDENCE-STATE 9b.COUNTY 9c.CITY OR TOWN
<br /> .- Nebraska Hall Grand Island
<br /> 9d.STREET AND NUMBER 9e.APT.NO 9f.ZIP CODE 9g.INSIDE CITY LIMITS
<br /> 1322 W 6th St. 68801 lit YES ❑ NO
<br /> ? 10a.MARITAL STATUS AT TIME OF DEATH KMarrled ❑Never Married 10b.NAME OF SPOUSE(First,Middle,Last,Suffix)If wife,give maiden name.
<br /> as ❑Married,but separated ❑Widowed ❑Divorced ❑Unknown Don Loveland
<br /> 11.FATHER'S-NAME (First, Middle, Last, Suffix) 12.MOTHER'S-NAME (First, Middle, Maiden Surname)
<br /> .f Donald Ellis Rose Stoddard
<br /> 'z 13.EVER IN U.S.ARMED FORCES?Give dates of service If yes. 14a.INFORMANT-NAME 14b.RELATIONSHIP TO DECEDENT
<br /> _ (Yes,no,or unk.) No Don Loveland Husband
<br /> R r I5.METHOD OF DISPOSITION 16a.EMBALME IGN&TUR 1 16b.LICENSE NO. 16c.DATE (Mo.,Day,Yr.) -
<br /> ❑Burial ❑Donation ' a1j.Ol,,fj(/ 1//0,3 May 1, 2010
<br /> A Cremation ❑Entombment 16d.CEMETERY,CREMATORY OR OTHER LOCATION CITY/TOWN STATE ,
<br /> ❑Removal U Other(Specify) Central Nebraska Cremation Service, Gibbon, Nebraska
<br /> 17a FUNERAL HOME NAME AND MAILING ADDRESS (Street,City or Town,State) 17b.Zip Code
<br /> s,, Kleine Funeral Home, 3213 W North Front St., Grand Island, NE 68803
<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 /> ,,7,171,
<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. I -
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE(Final (a) c 11(171.- •
<br /> -11 - - I onset to death
<br /> � dlaeaseorcond8lonresulting DUE TO,OR AS A CONSEQUENCE OF:
<br /> In death) rr(
<br /> ts
<br /> Sequentially list conditions,If (b) ,)l r�`,713, «l l(� o r (arnz holr,i� 1-2 wiw. $
<br /> r
<br /> any,leading to the cause listed DUE TO,OR ACACONSEQUENCEOF: I onset to death
<br /> -' online a. I
<br /> 4n
<br /> Enter the UNDERLYING CAUSE
<br /> (disease orin)urythatInitiated (c)
<br /> ,;1 theevents resulting In death) DUE TO,OR AS A CONSEQUENCE OF: I onset to death
<br /> UST
<br /> (d)
<br /> ,;�.;1 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 /> s,:-k OR CORONER C NTACTED7
<br /> ,-ti.S
<br /> -, ❑ YES NO
<br /> 4.,0 20.IF FEMALE: 21a.MANNER OF DEATH 21b.IF TRANSPORTATION INJURY 21c.WAS AN AUTOPSY PERFORMED?
<br /> Natural ❑Homicide ❑DrNer/Operator
<br /> a-_1 NgNot pregnant within past year ❑YES NO
<br /> 2' ❑Pregnant at time of death ❑Accident❑Pending Investigation ❑Passenger
<br /> -.4,,S Li Pedestrian
<br /> i. "^f ❑Not re nant,but pregnant within 42 days of death 21d.WERE AUTOPSY FINDINGS AVAILABLE TO
<br /> D 9 9 Y ❑Suicide ❑Could not be determined
<br /> ❑Npt pregnant,but pregnant 43 days to 1 year before death ❑Other(Specify) COMPLETE CAUSE OF DEATH?
<br /> ai. 9 Y
<br /> ��r
<br /> 1-7.-.,', ❑Unknown If pregnant within the past year ❑ YES ❑NO
<br /> rii-. 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 /> m
<br /> 2 22d.INJURY AT WORK? 22e.DESCRIBE HOW INJURY OCCURRED
<br /> r?<
<br /> r ❑YES ❑NO
<br /> 22f.LOCATION OF INJURY•STREET&NUMBER,APT.NO. CITY/TOWN SIAtt ZIP CODE
<br /> P-04 23a.DATE OF DEATH(Mo.,Day,Yr.) 24a.DATE SIGNED(Mo.,Day,Yr.) 24b.TIME OF DEATH m
<br /> a �,g >.g
<br /> � na-9R-9n1n ..oz
<br /> )�i I,'y 23b.DATE SIGNED(Mo.,Day,Yr.) 23c.TIME OF DEATH I_1 24c.PRONOUNCED DEAD(Mo.,Day,Yr.) 24d.TIME PRONOUNCED DEAD
<br /> M
<br /> o Wo 04-29-2010 q• m Es;o
<br /> o c 234.To the best of my knowledge,death occurred at the time,date and place 1-...= 24e.On the basis of examination and/or investigation,in my opinion death occurred at
<br /> an he ca e(s)stated. Signature and Title) p U the time,date and place antl due to the causes)stated.(Signature and Title)
<br /> Fo gig�,:ti < I n 8t
<br /> '- 25.DID TOBACCO U INTRIBUTE TO THE DEATH? 26a.HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b.WAS CONSENT GRANTED?
<br /> '`?Y" ❑YES ❑NO ❑PROBABLY „UNKNOWN CI YES O Not Applicable if 26a is NO ❑YES ❑NO
<br /> n 27.NAME,TITLE AND ADDRESS OF CERTIFIER(PHYSICIAN,CORONER'S PHYSICIAN OR COUNT Y ATTORNEY)(Type or Print)
<br /> ; iN Douglas D. Herbek, MD, 2444 4 Faidley Ave. , Grand Island NE 68803
<br /> 1 28a.REGISTRAR'S SIGNATURE 4' Iry YV 28b.two BY f [ tO(Mo.,Day,Yr.)
<br /> 6
<br /> J&\ y
<br /> HHS-61 11/03(55061)
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