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d,. 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) - Martyn Junior Shunkwiler 2. SEX Male ' 3 DATE OF DEATH '(Mo., Day,Yr.) Ma °' 2006 I 4 . CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Fairfield, Nebraska 5a. AGE -Last Birthday (Yrs.) 71 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo.,Day, Yr.) MOS. DAYS HOURS MINS. October 24, 1934 7. SOCIAL SECURITY NUMBER 507-34-6023 8a. PLACE OF DEATH HO S PITAL: S In patient �: ❑ Nursing Home/LTC ❑ Hospice P Facility ❑ ER /Outpatient ❑ Decedent's Home ❑ cQ4 ❑ Other(Spedfy) f 8b. FACILITY -NAME (1f not institution, give street and number) St. Francis Medical Center 8c. CITY OR OF DEATH (Include Zip Code) - -- Grand Island 68803 8d. COUNTY OFDEATH Hall 9a. RESIDENCE -STATE i Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 115 S. Madison St. 9e. APT. NO 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS cx YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH DO Married 0 Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Janet L. Klein 11. FATHER'S -NAME (First, Middle, Last, Suffix) Martyn Shunkwiler 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mildred Campbell 13 _EVER IN U.S. ARMED FORCES? Give dates of service If yes. , 10/4/54- 9/25/58 (Yes,o orunk.) 14a. INFORMANT-NAME Janet L. Shunkwiler 14b. RELATIONSHIP TO DECEDENT wife 15. METHOD OF DISPOSITION ❑Burial ❑Donation OiCremation ❑ Entombment ❑Removal ❑ Other (Specify) 16a.EMBALMER- SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr. ) May 3, 2006 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Service Gibbon, Nebraska 178. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust St., Grand Island,NE �r3�`. �f .;! 4 ��hF �..i {o+rP ,N •� :.`•'! � a.. _. " _ • ;. .,._ ° <, ... ° �.x . , y „- •. i i , -� ... ry =y 18. PART I. Enter the chafevents -- diseases, Injuries, or complications- -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE m o respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. 1 IMMEDIATE CAUSE: - r I onset I � . s�. , IMMEDIATE CAUSE (Final (a) a.11/1 GP�f „' 1 1-e- I 17b. Zip Code 68801 INTERVAL to death f� ahrf ' e:u disease or condition resulting 1 onset to death 9 DUE TO, OR AS A CONSEQUENCE OF: in death) >!e�l + D ol4 heors I vie II;.. ) I Sequentially list conditions, If (b ( any, leading to the cause listed I onset to death DUE TO, OR AS A CONSEQUE O on line a. / Enter the UNDERLYING CAUSE �.f� /- 2 A (disease or Injury that Initiated (c) OP f4 4 1�� ®F «rf °n j1,Yl the events resulting in death) - DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST (rO 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. // ,�/ f56(" 01 C r 0,40,41/ (0740 (0740 / / 7 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES [t�100 20. IF FEMALE: 1.3 Not pregnant within past year 0 Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if within the 21a. MANNER OFDEATH Natural ❑ Homicide ❑ Accident❑ Pending Investigation ❑Suicide ❑ Could not be determined 21 b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ❑is i 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO site, etc. (Specify) pregnant past year 228. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction �t4 22d. INJURY AT WORK? CI YES El NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET B NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) May 3, 2006 a fi r;= ° i_� n aa� N Z i w O . p O 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIME OF DEATH m 23b. DATE SIGNED (Mo., Day, Yr.) .5 23c.TIME OF DEATH 01:01 A.m 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD m 23d. To the best of my knowledge, death o urred at the time, date and place and due to the cause(s) st ed. (S' ature and Title) • 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 Title ) • ' X 25. DID TOBACCO USE CONTRIBUTETOTHEDEATH? ❑ YES NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES �•NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ¢(NO - 27. NAME, TITLI AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Gary Settle', M.D.,2116 W. Faidley Ave.,Grand Island, NE 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) MAY 9 2006 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BEA TRUE COPY OF THE ORIGINAL-RECORD QN WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHIC H IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. = _ DATE OF ISSUANCE MAY 11 2006 LINCOLN, NEBRASKA 201404494 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPO OF DE