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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND,HUMA, N SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT QF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL ISECO) O.
<br />DATE OF ISSUANCE
<br />11/06/2013
<br />LINCOLN, NEBRASKA
<br />1. DECEDENTS-NAME (First, gl MMdI. `, tap. Mello)
<br />Lawrence Douglas McPhillips
<br />4.. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hastings, Nebraska
<br />T. SOCIAL SECURITY NUMBER
<br />505-44-2808
<br />60.FACILUTriNAME P not llatltotloll,gM stoma .60weber)
<br />.316 Sheridan Fla .e
<br />ec. crry OR TOWN OF DEATH (Inelud. Zip .0044)
<br />Grand Island 68803
<br />Se. RESIDENCE-STATE
<br />Nebraska
<br />ed. STREET AND NUMBER
<br />1316 Sheridan Place
<br />10.. MARITAL STATUSAT TIME OP D!ATh Manhsd ` `Q New
<br />Mw
<br />❑ Marled, but apanbd ❑: WWowsd ❑ Dbrole.d 0 Unknown
<br />11. FATIERbNAME (First. ',MMdte. Last SuU4t)
<br />Lawrence D McPhillips
<br />12. EVER BM U.S. ARMED FORCES? Glw dabs of s.Mce E WM.
<br />eta No, of 1)11114 ' No
<br />16. METHOD OF DISPOSITION
<br />Osumi Cloonseon
<br />®Enmwles : ❑6.1aasuom
<br />❑urmo w ❑° 1PWP)
<br />17a. FUNERAL HOME NAME AND MAIUNO ADDRESS Minot. Clly or Town. Stab)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand island, Nebraska
<br />'` anu•m&y Mu conditions. >
<br />any. leading t0 ON:Caum listed
<br />on Eno a. DUE TO, OIRAS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE: 0)
<br />(dinars or Injury
<br />nulli Whited
<br />enim
<br />tl '. DUE TO.OR AS A CONSEQUENCE OF:
<br />m.atlb rasuitllp in d.atl1)
<br />LAST ';;
<br />` th IF FEMALE:
<br />7
<br />NOt pngumnt.4Mb past your
<br />❑Pr6Onadat Erne ofGrath ?.
<br />❑Not prssnwd. but pr.snrd wlslln 42 days of death
<br />❑Not pnpnad. 0111 Pregnant 43 days to 1 yw before death
<br />❑Unl now I If pepnaM within** pea yaw
<br />22a. DATE OF. INJURY (Mo., Day, Yr.)
<br />O.Y. Yr.) 2 TIME OF
<br />220. DA
<br />,l f' 7
<br />pb .000NTY
<br />Hall
<br />1a.EMBAIMER- IGNATURE
<br />Not Embalmed
<br />276. Tile OF INJURY
<br />m
<br />231. To the bast of my knowledge,
<br />and due , _ „ alld TWO
<br />STATE OF NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />ea. AGE-Last Birthday
<br />(W
<br />Julia Hulett
<br />Julia McPhillips
<br />at the t dote and play
<br />72
<br />21 . MANNER OFDEATH
<br />*Meal ❑ Homicide
<br />❑ Accident ❑ Fending Boast gatlo11
<br />❑ Sulold. ❑ Could not bo dNMNdnad
<br />1
<br />USE CONTRIBUTE TO THE DEATH?
<br />❑ ►10 ❑ PROBABLY ❑ UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CER11ilER (Typo or Print)
<br />Jane McDonald MD 800 Alpha St Grand Island N
<br />2e1, REGISTRARS SIGNATURE
<br />201401370 STAY PE
<br />AS,S�TAN Ti RE
<br />DEP4, TME CIE
<br />HUMAN VF ICES
<br />6b, UNDER 1 YEAR
<br />MOB.
<br />ec. ctTYof Tow11
<br />Grand Island
<br />DAYS
<br />ea PLACE OF DEATH
<br />(.: ❑ t 1 1
<br />❑.
<br />amostputes
<br />❑ D
<br />10b. NAME OF SPOUSE (First, .18100111. Lost.
<br />16d. CEMETERY, CRMIATORYOR OTHER LOCATION
<br />Centel Nebraska Cremation Services
<br />2. SEX
<br />Male
<br />So. UNDER 1 DAY
<br />HOURS I? Mew.
<br />QUO :Nanbp Hans/LTC
<br />Dowdont's Home
<br />0Mw(spary)
<br />ed COUNTY OF DEATH
<br />Hall
<br />M. APT. NO. M. ZIP CODE
<br />68803
<br />booboo vas, - moan
<br />:lrm
<br />12. MOTHEWS -NSW (FM. WWI*. Malden Summer
<br />Therese M O'&ien
<br />3. DATE OF DFATM (Mo..D.y.Y') :.
<br />October 27, 2013
<br />6. DATE OF BIRTH (leo., Day, Yr.)
<br />September 8,1941
<br />O Hee.L.Fa1E11
<br />�mu-1
<br />6b. LICENSE NO.
<br />crrnrowN
<br />Gibbon
<br />1e. PART S. OTHER MOMFICANT CCU Ia14SHRbp brim Wilt but not naldno In tha d car. shwa 111 PTT L
<br />agr iN/�•
<br />N ��M•a ("a (1419 , .�.( .r1 r y �ii r�s1
<br />21b. IF TRANSPORTATION INJURY
<br />❑ om,eosaaaa
<br />Pasurigar
<br />❑ F«NNdon
<br />❑ Other (arroriy)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />E 68803
<br />•
<br />es. BIKE CRY LIMITS
<br />® Yes 0
<br />141). RELATIONSHIP TO DECEDENT I.
<br />Spouse
<br />lee. DATE GM., Day, Yr.)
<br />October 28, 9.2013
<br />24.. DATE SIGNED (Mo., Day, Tr.) - 240.111! 0f DEATH
<br />260. HAS ORGAN OR T NATION BEEN CONSIDERED? 260. WAS CONSENT GRANTl0?
<br />❑ Yea No
<br />STATE
<br />Nebraska
<br />176..8p Code
<br />68801
<br />IS. PART L6nh u...fea6.gfysala• door" b11 aewpwIOr. Mn OW,enrdY. don*. 00 MX enytimnInd swotslaw, al *NOW NNW, .
<br />mpsaterr am1,erwa60wrllawten wabae showing dwMloleph DO Nor AMREVN1I.MOW oaY I:rr.n *DM Add addMonwww 611.1.1.17.
<br />IMMEDIATE CAUSE:
<br />asmouITE emits (Ana
<br />ammo or
<br />M Oasts) in moulting
<br />7 I %
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET i:NUMSER. APT. NO. CI YRROKM
<br />CAUSE OF DEATH (See Instructions and`<examplee)
<br />ions* to death
<br />111. WAS.UEDICAL EXAMEN
<br />OR COROHER.00YTAC',IM19
<br />❑Yes
<br />21d WERE AUTOPSY FNIDINGS AYAI W LR
<br />70 COMPLETE bP DEATH?
<br />❑ WIS
<br />STATE S' 2iCDDE
<br />24d.111i*: PRONOUNCED . DEAD
<br />NOV 4 2013
<br />APPROXIMATE INTERVAL '.
<br />t onset 61 desh >.
<br />i onat to death
<br />onset to death
<br />21c. WASAN AUTOIT D
<br />22e. PLACE OF INJURY-At holm. Tam street, factory, office building, .on.puctbn aRs,.stu. (8p0ONy)
<br />250. DATE FILED SY REGISTRAR (Mo.. Day: Yr.)
<br />m
<br />Not Applicable N no is NO OYES h
<br />24.. On tins basis of wantination andlor YndutlWtlon. In my oPbton WWII occurred
<br />at rim ens, dab and plae1 and dim to the eany1) nbted. (S1gmton and TM.) :,
<br />
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