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1. DECEDENTS -NAME (Flat, Middle, Last, Settle) vase II • • sv� • _ v • r _
<br />Donald Leroy Moms
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo.,Day Yr.) t
<br />June 26, 2014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />8a. AGE -Last Birthday
<br />(Yrs.)
<br />91
<br />6b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />October 241922
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINE.
<br />7. SOCIAL SECURITY NUMBER
<br />553 -26 -6444
<br />Sa. PLACE OF DEATH
<br />=MALI it inpatient
<br />❑ ER/Outpatient
<br />0 DOA
<br />Ql� 5 ❑ Nursing Homa/LTC ❑ Hospice Facility
<br />❑ Decedent's Home
<br />poth.Kap.uy)
<br />Sb. 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 />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9e. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1008 W. 7th St.
<br />9e. APT. NO.
<br />If. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® Yes ❑ No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Monied
<br />❑ Married but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) S wife, give maiden name.
<br />Max Pauline Bebemiss
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Walter Leroy Moms
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Sophia Christine Spiehs
<br />13. EVER St U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yea, No or link.) Yes 04/09/1943- 12/31/1945
<br />14a. INFORMANT -NAME
<br />Maxine Pauline Morris
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16. METHOD OF DISPOSITION
<br />Daudet ❑oOcedon
<br />l renedion DEntornwn.re
<br />Demme palwtawaryl
<br />16a. EMBALMER- SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />June 28, 2014
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<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 />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />IL PART 1. Enter the NltlosLmotr - dNeams, Wades, or canplleetnne -ties directly caused the death. DO NOT enter terminal some such an cardiac arrest, APPROXIMATE INTERVAL
<br />Mpbalary arrest, or ventricular frodlledon vdthaut Showing the .tlology DO NOT ABBREVIATE. Enter only an teem on a dm. Add addldonel Mme if nsasuly.
<br />IMMEDIATE CAUSE: onset to death
<br />disease CAUSE (Final \' �° ti.,-- I /
<br />' disease e or condition resulting a) 1 �
<br />In death)
<br />DUE TO, OR AS A C EQUENCE OF: n.i�V�W
<br />Sequentially n leading to t conditions, se listed e If
<br />any, leadirlp te the cause Bested O)
<br />onset to death
<br />on line a. DUE TO, OR AS A NSEQUENCE OF: V' onset to death
<br />Enter the UNDERLYING CAUSE el
<br />(disease or Injury that Initiated
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST
<br />d)
<br />It PART IL ON 8 WICANT CONDITIONSCondtOons con
<br />• (', w..0' 1 O Las
<br />Eng to th bu rat resulting in (CA.�. unds - '( r dyl�p ewes giv ^ l In ; -
<br />W'•+
<br />J•f�. !Vila by ` Nadi :
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑YES At NO
<br />20. IF FEMALE:
<br />❑ Pot pregnant within poet year
<br />❑Pregnant at time of death
<br />ONot pregnant, but pregnant within 42 days of death
<br />ath
<br />ONot pregnant, but pregnant 43 days to 1 year before death
<br />❑Unknown If pregnant within the past year
<br />21a. MANNER OF DEATH
<br />,] Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />rn
<br />❑ Suicide ❑ Could not be detadned
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Paseenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21 WAS AN AUTOPSY PERFORMED?
<br />0 YES arO
<br />21d. WERE
<br />M TO COMPLETE LE E CAUUSE SE O FINDINGS AVAILABLE
<br />T O DEATH?
<br />p YES 0 NO
<br />22e. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m l
<br />22€. PLACE OF INJURY -At home, farm, street, factory, Office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY • STREET a NUMBER, APT. NO. CITWTOWN STATE MP CODE
<br />1
<br />u. a§t
<br />o
<br />a _
<br />o O
<br />~
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />4/- 1 � 9
<br />it 2z
<br />0
<br />a i
<br />g � j
<br />B O
<br />~
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />23b. DATE SIGNED o. Day, Yr.)
<br />23c. TIME OF DEATH
<br />l 109 A m
<br />24c. PRONOUNCED DEAD (Mo„ Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />{.t ey
<br />23d. o the b of ^mm f knbwiedge, death o ccurred at the time, date and place
<br />end due to the cauSe(,a) stated. (Slpnatdro and Title)
<br />LJ
<br />24e. On the balls of examination and/or Investigation, In my opinion death occurred
<br />at the time, date and place and due to the causes) stated. (Signature and Title)
<br />26. DID TOBACCO USE CO TO THE DEATH?
<br />❑ YE8 ❑ NO m PROBABLY 0 UNKNOWN
<br />/ D 1 RESS
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES At NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND Ate OF CERTIFIER (Type or Print)
<br />William Landis M.D. 2444 W. Faidley Ave., Grand Island, NE 68803
<br />26a. REGISTRAR'S SIGNATURE
<br />29b. DATE FILED BY J UL (Mo., D 14 )
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<br />DATE OF ISSUANCE
<br />07/07/2014 201404589
<br />LINCOLN, NEBRASKA
<br />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 NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />STANLEY S .,COOPER
<br />ASSISTANT ST4,TE REGI$7'RAR
<br />DEPARTMENT'OF HEALTH AND
<br />HUMAN SERVICES
<br />24
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