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ry 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Paul E. Imler 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) April 24, 2008 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Republic County, Kansas 5a. AGE -Last Birthday (Yrs.) 74 5b. UNDER 1 YEAR 5o. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.) July 20, 1933 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 514 -34 -0468 85. PLACE OF DEATH HOSPITAL: 0 inpatient Da 11Ea ❑NuraingHome/LTC ❑ ER/Outpatient a Decedent'e Home ❑ c01 ❑ Other(Specify) ❑ Hospice Facility ,-. 8b. FACILITY -NAME (If not Institution, give street and number) 318 Church Street ( 80. CITY OR TOWN OF DEATH (Include Zip Code) Doniphan 68832 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN - Doniphan WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE OCT 2 3 2013 LINCOLN, NEBRASKA 318 Church Street 10a. MARITAL STATUS AT TIME OF DEATH married ❑ Never Married rrled, but separated ❑ Widowed ❑ Divorced ID Unknown 11. FATHER'S -NAME (First, William 13. EVER IN U.S. ARMED FORCES? L11v&d_tgapf ge,ylce If yea. (Yee, no, orunk.) Yes 12- )2- 1 1 1 77 9 7 5 r 5 15. METHOD OF DISPOSITION ❑ Burial ❑Donation XlCremation ❑Entombment El Removal ❑ Other (Specify) 17e. FUNERAL HOME NAME AND MAIL NO ADDRESS (Street, City or Town, State) Livin . ston - Butler - Volland Funeral Home IMMEDIATE CAUSE (heal dI eseorcoMtIon Indeeth) Sequentlellyllatcondf6ons,If @) any, leading to the muse listed on line a. Fntsr the UNDERLYING CAFE (disease or Injury thatinitlatad the events reealtteg In death) LIST DUE TO, OR AS A CONSEQUENCE OF: (c) Middle, 16a. EMBALMER- SIGNATURE No Embalming 201309688 1 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND'SUPPOBT . ^ C OF DEATH L Last, Imler Suffix) 145. INFORMANT -NAME _Eloise Imler 16d. CEMETERY, CREMATORY OR OTHER LOCATION BV Cremation Center d/z DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: STATE OF NEBRASKA ga. APT. NO 9f. ZIP CODE 68832 lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wile give maiden name. Eloise Dunstan 12. MOTHER'S -NAME (First, Nora 16b. LICENSE NO. CITY / TOWN Hastings 1225 North Elm Avenue H =a n s Nebraska M. FART I. Ender the thuin ai evenfa-- diseases, Injuries, or compiicatlone- -that directly caused Ins death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without ehowIng the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. IMMEDIATE CAUSE: i onset to death d2/7 «rng0/4.. 4004 di% 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given In PART I. C6C4 20. IF FEMALE: ❑ Not pregnant within pest year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days 101 year before death ❑ Unknown it pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 224. INJURY AT WORK? 221. LOCATION OF INJURY - STREET a NUMBER, APT. NO. = J fl go ❑ YES . NO 23a. DATE OF DEATH (Mo., Day, Yr.) April 24, 2008 23b. DATE SIGNED Mo., Day, Yr.) %•2 zoo b' 23d. To the best of my knowledge, deal and due tot cause fated 28a. REGISTRAR'S SIGNATURE (y/1-674067)4 Cee /,_i*,'' 22b. TIME OF INJURY m 22e. DESCRIBE HOW INJURY OCCURRED 2 a. MANNER OF DEATH latural ❑ Homkdde ❑ ACOldent❑ Pending Investigation ❑ Suicide ❑ Could not be determined "Yr, CRY/TOWN 23c.TIME OF DEATH 8:45 P m urred at the time, date and place and Title) • 0 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) Middle, ❑ YES 22c. PLACE OF INJURY -At home, farm, street, 'victory, office building, construction site, etc. (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24b.TIME OF DEATH STANLEY S. ASSISTANT STATE: REGISTRAR DEPARTMENT DF HEALTH AND HUMAN SERVICES Malden Surname) Osborne 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr. ) April 25, 2008 Nebraska 17b. Zip Code 68901 APPROXIMATE INTERVAL onset to death onadt to death onset to death STATE 9g. INSIDE CITY LIMITS X3 YES ❑ No I9. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES jt NO 21o. WAS AN AUTOPSY PERFORMED? 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO ZIP CODE 24d. TIME PRONOUNCED DEAD m m 24e. On the basis of examination and/or investigation, In my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Titre) • 25. DIDTOBACCO USE CONTRIBUTE TOTHE DEAT . 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES XNO ❑ PROBABLY ❑ UNKNOWN ❑ YES NO 27. NAME. TITLE AND ADDRESS OF CERTIFIER ( PHYSICIAN, CORONER'S PHYSICIAN OR COUN ATTORNEY) (Type or Print) Gary L. Settje, M.D., 2116 West Faidley, Suite 400, Grand Island, Nebraska 68802 28b. WAS CONSENT GRANTED? Not Applicable If 25n is NO ❑ YES Ni/R0 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) MAY 8 2008 HHS-61 11/03 (55061)