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STATE OF NEBRASKA
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES,IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAcSSO.'IEPARTMEN7`bF HEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR AL'.RECORDS,
<br /> DATE OF ISSUANCE *`�
<br /> 201307096 SrANLSYS.:COQPER
<br /> 08/08/2013 ASSZ TA rT SKATE REGIS.TRAA
<br /> DEPARTMENT OF HEALTH AID'
<br /> LINCOLN, NEBRASKA HUMAI%SEKVICE5 .,•' st''':,
<br /> STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERy CEt -,_:'1t; ' ' 10 00646
<br /> CERTIFICATE OF DEATH 't':. -4-`4#1);- 'j+ °`'
<br /> .1.DECEDENT'S-NAME (First, Middle, Last, Suffix) 2.SEX 3.DATE OF DEATH(Mo.,Day,Yr.)
<br /> Warren Nelson Hays Male March 8,2010
<br /> 4.CITY AND STATE OR TERRITORY,OR FOREIGN COUNTRY OF BIRTH 5a.AGE-Last Birthday b.UNDER 1 YEAR 5c.UNDER 1 DAY 8.DATE OF BIRTH(Mo.,Day,Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br /> Petersburg,Nebraska 88 I March 13, 1921
<br /> 7.SOCIAL SECURITY NUMBER 8a.PLACE OF DEATH
<br /> 505-24-6579 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 /> W
<br /> o
<br /> Saint Francis Medical Center ❑DOA ❑Other(Specify)
<br /> U
<br /> W 8c.CITY OR TOWN OF DEATH(Include Zip Code) I 8d.COUNTY OF DEATH
<br /> o Grand Island 68803 Hall
<br /> 'l 9a.RESIDENCE-STATE 9b.COUNTY CITY OR TOWN
<br /> DDi Nebraska I Hall I 9c.Grand Island
<br /> 7 9d.STREET AND NUMBER 19e.APT.NO. 9f.ZIP CODE 9g.INSIDE CITY LIMITS
<br /> LL. 1512 N.Ruby Ave. I 68803 I ® YES ❑ NO
<br /> 10a.MARITAL STATUS AT TIME OF DEATH®Married ❑Never Married 10b.NAME OF SPOUSE(First, Middle, Last, Suffix)If wife,give maiden name
<br /> 1:3
<br /> E ❑Married,but separated ❑Widowed ❑Divorced ❑Unknown Janet Olk
<br /> i 11.FATHER'S-NAME (First, Middle, Last, Suffix) 12.MOTHER'S-NAME (First, Middle, Maiden Surname)
<br /> Oliver Hays Sylvia Nelson
<br /> E 13.EVER IN U.S.ARMED FORCES? Give dates of service if Yes. 14a.INFORMANT-NAME 14b.RELATIONSHIP TO DECEDENT
<br /> 3 (Yes,No,or Unk.)Yes 12/27/1943-06/08/1945 Dan Hays Son
<br /> 2 15.METHOD OF DISPOSITION 16a.EMBALMER-SIGNATURE 16b.LICENSE NO. 16c.DATE(Mo.,Day,Yr.)
<br /> 2 ❑Burial ❑Donation
<br /> Not Embalmed March 10,2010
<br /> ®Cremation 0 Entombment 16d.CEMETERY,CREMATORY OR OTHER LOCATION CITY/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 /> All Faiths Funeral Home,2929 S.Locust Street,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 H necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE(Final a)Senescence Immediate
<br /> disease or condition resulting
<br /> in death) DUE TO,OR AS A CONSEQUENCE OF: onset to death
<br /> Sequentially list conditions,if b)
<br /> any,leading to the cause listed
<br /> on line a. DUE TO,OR AS A CONSEQUENCE OF: 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 /> IX
<br /> W
<br /> LL 20.IF FEMALE: 21a.MANNER OF DEATH 21b.IF TRANSPORTATION INJURY 21c.WAS AN AUTOPSY PERFORMED?
<br /> P ❑Not pregnant within past year ®Natural 1:1 Homicide ❑Driver/Operator ❑ YES ® NO
<br /> U 0 Pregnant at time of death ❑Accident ❑Pending investigation ❑Passenger
<br /> ❑Not pregnant,but pregnant within 42 days of death ❑Pedestrian 21d.WERE AUTOPSY FINDINGS AVAILABLE
<br /> Et ❑Suicide ❑Could not be determined TO COMPLETE CAUSE OF DEATH?
<br /> ❑Not pregnant,but pregnant 43 days to 1 year before death ❑Other(Specify) ❑ YES ❑ NO
<br /> ❑Unknown If pregnant within the past year
<br /> at
<br /> E 22a.DATE OF INJURY(Mo.,Day,Yr.) 22b.TIME OF INJURY 122c.PLACE OF INJURY-At home,farm,street,factory,office building,construction site,etc.(Specify)
<br /> 8
<br /> Sr 22d.INJURY AT WORK? 22e.DESCRIBE HOW INJURY OCCURRED
<br /> F
<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 /> .2 W t I= March 10,2010 04:30 PM
<br /> I E } 23b.DATE SIGNED(Mo.,Day,Yr.) 123c.TIME OF DEATH /E 1 y 24c.PRONOUNCED DEAD(Mo.,Day,Yr.)24d.TIME PRONOUNCED DEAD
<br /> Eu,z P<Z March8,2010 04:30 PM
<br /> 8 0 9d.To the but of my knowledge,death occurred at the time,date and place 8 k 0
<br /> ,y 24e.On the basis of examination and/or Investigation,In my opinion death occurred at
<br /> $ c and due to the cause(s)stated.(Signature and Title) 2 ZZ p the time,date and place and due to the cause(s)stated.(Signature and Title)
<br /> 12 act Sarah Carstensen,Hall Deputy County Attorney
<br /> 25.DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a.HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b.WAS CONSENT GRANTED?
<br /> ❑YES ❑NO ❑PROBABLY ® UNKNOWN ❑YES ®NO Not Applicable If 26a Is NO ❑YES ❑NO
<br /> 27.NAME,TITLE AND ADDRESS OF CERTIFIER(Type or Print
<br /> Sarah Carstensen,Hall Deputy County Attorney,231 S.Locust,P.O.Box 367,Grand Island,Nebraska,68802
<br /> 28a.REGISTRAR'S SIGNATURE A. 28b.DATE FILED BY REGISTRAR(Mo.,Day,Yr.)
<br /> March 10,2010
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