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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />NOV 2 8 2007
<br />LINCOLN, NEBRASKA
<br />201307219
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Lloyd Charles Zigler
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kearney, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506 -46 -1628
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Saint Francis Medical Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />2104 Barbara Ave
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Donald Zigler
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit-) No
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑Donation
<br />❑ Cremation ❑Entombment
<br />❑Removal ❑Other(Specify)
<br />on line a.
<br />Enter the UNDERLYING CAUSE c)
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unknown if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 20, 2007
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />9b. COUNTY
<br />Hall
<br />18d. CEMETERY, CREMATORY OR OTHER•COCATION
<br />DU AS IWCONSEQUENCE OF:
<br />E
<br />thelp
<br />22b. TIME OF INJURY
<br />of my knowledge, death occurred at the time, date and place
<br />e caJuse(s) stated. (S(rSnature and Title}
<br />25. DID T • _ • CCO SE CONTRIBUTE TO THE E�TH?
<br />❑ YE r 0 ❑ PROBABLY ❑UNKNOWN
<br />21 MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />23c. TIME OF DEATH
<br />02:20 a. m
<br />6a. AGE -Last Birthday
<br />(Yrs.)
<br />65
<br />6b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />9e. APT. NO.
<br />16b. LICENSE NO.
<br />/e 7i
<br />c
<br />_4 4/66
<br />28a. HAS ORGAN OR TISSUE DON 110N BEEN CONSIDERED?
<br />❑ YES l
<br />28a. REGISTRAR'S SIGNATURE
<br />2 SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />8a. PLACE OF DEATH
<br />)IOSPITAL• ® Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER: ❑ Nursing Home/LTC ❑ Hospice Facility
<br />❑ Decedent's Home
<br />❑ Other(Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Karen Aldrich
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Evelyn Day
<br />14a. INFORMANT -NAME
<br />Karen Zigler
<br />8d. COUNTY OF DEATH
<br />Hall
<br />CITY/TOWN
<br />Grand Island City Cemetery Grand Island
<br />(77 = 24
<br />qA � ` Cl - �j
<br />a . QF QEATH- Mo.,Qay,Yr.)
<br />1416"ve iier!20, 2007
<br />( 6.,pATE OFBiRTH (Mo., Day, Yr.)
<br />February 3, 1942
<br />16c. DATE (Mo., Day, Yr.)
<br />November 23, 2007
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Drlver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />9g. INSIDE CITY LIMITS
<br />El Yes ❑ No
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />onset to death
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of event! - diseases, Injuries, or complications -that directly caused the death. DO NOT enter Mminal events such as cardiac wrest,
<br />respiratory arrest, or ventricular fibrillation without showing t e etiology. DO NOT ABBREVIATE. Ether only ons cause on a line. Add additional lines it necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting a) (� t
<br />In death) �-T n
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Sequentially list conditions, If b)
<br />any, leading to the cause listed
<br />DUE TO, OR/i¢ A CONSEQUENCE OF:
<br />6,42.2-
<br />onset to dea
<br />r -z w7
<br />(disease or Injury that Initiated
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />d)
<br />onset to d
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER ACTED?
<br />❑ YES
<br />NO
<br />❑ YES
<br />21c. WAS AN AUTOPSY➢ERFORMED?
<br />0
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE SE OF DEATH?
<br />❑ YES NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />CITY/TOWN
<br />STATE ZIP CODE
<br />24b. TIME OF DEATH
<br />m
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />24e. On the basis of examination and/or Investigation, in my opinion death occurred
<br />at the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable H 26a is NO ❑ YES
<br />N
<br />27. NAM , r LE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />ohn A. Wagoner, M.D. 800 Alpha St., Grand Island, Nebraska 68803
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />NOV 2 6 2007
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAMSE
<br />CERTIFICATE OF DEATH
<br />
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