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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH•A! D HUM.41V SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA,DEPARTME:1VT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIT?4L. Q1 QSf,` . 1. DECEDENT'S -NAME (First, LeMoyne 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Osceola, Nebraska 7. SOCIAL SECURITY NUMBER 508 -30 -0054 8b. FACILITY -NAME (If not institution, give street and number) Veterans Hospital 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 9a. RESIDENCE -STATE - • 9d. STREET AND NUMBER 4179 Michigan Ave. 10a. MARITAL STATUS AT TIME OF DEATH YI Married ❑ Never Married ❑ Married, but separated 0 Widowed ❑ Divorced 0 Unknown 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation DiICremation ❑ Entombment 0 Removal ❑ Other (Specify) IMMEDIATE CAUSE (Final disease orcondidonresulting In death) Sequentially list conditions, M any, !trading tothecauselisted on line a. Enterthe UNDERLYING CAUSE (disease or in)ury that Initiated the events resulting In death) LAST �eCt1� C.\IA (43 o 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death 0 Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Vr.) 22d. INJURY AT WORK? ❑ YES [t10 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT. NO. 23a. DATE OF DEATH (Mo., Day, Yr.) 0 February 17,. 2011 s a= te a E mo 23b. DATE SIGNED (Mo., Day, Yr.) 23c.TIME OF DEATH $ .0 1:58 •.m 23d. To t DATE OF ISSUANCE FEB IS' 2011 LINCOLN, NEBRASKA • C best of my kn . uetothe aus• I 28a. ° EGISTRAR'S SIGNATURE STANLEY .7c4cv ASSISTANT StArg TF 4R DEPA'fTMENT OF HEALTH AND HUMAN SEWICES ' • . s t (rt ,, STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT CERTIFICATE OF DEATH DUE TO, OR AS A CONSEQUENCE OF: (c DUE TO, OR AS A CONSEQUENCE OF: (d) ledge, dea s) stated. Middle, Emil 16a. EMBALMER - SIGNATURE Not Embalmed 22b. TIME OF INJURY m 22e. DESCRIBE HOW INJURY OCCURRED Last, h occur ed at the time, date and place Si�atyre and Title ) i' STATE OF NEBRASKA CITY/TOWN 201406957 5a. AGE -Last Birthday (Yrs.) 78 Suffix) 8a. PLACE OF DEATH HOSPITAL: 5b. UNDER 1 YEAR MOS. 9b, COUNTY 9c. CITY OR TOWN DAYS Inpatient ❑ ER /Outpatient ❑ 004 2. SEX lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife give maiden name. Jaguel n Rae Reznor 5c. UNDER 1 DAY HOURS MINS. 8d. COUNTY OF DEATH Hall .8R 1 -i. 9e. APT. NO 9f. ZIP CODE 68803 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, tl • • • s 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. 14a. INFORMANT -NAME (YX,esrunk.) /18/1951- 2/9/195: Jaquelyn Monson 16b. LICENSE NO. 18. PART I. Enter the chain of events -- diseases, injbrles, or complications- -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary IMMEDIATE CAUSE: {{�� (a) Q,CN(6 ((� 1 � M OS 0.r (b) ( c \0.R. rOLc 1 n`Slo t s 6 • 1�ti �1 • DUE TO, OR AS A CONSE CE 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21a. MMMAIIINNER OF DEATH >,a Natural ❑ Homicide ❑ ` Accident ❑ Pending Investigation ❑ Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator 0 Passenger ❑ Pedestrian ❑ Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) STATE 24c. PRONOUNCED DEAD (Mo., Day, Yr.) MO ❑ Nursing Home/LTC ❑ Hospice Facility ❑ Decedent's Home ❑ Other(Specify) 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust St., Grand Island,NE 3. DATE OF DEATH (Mo., Day, Yr.} y 17,2011 6. DATE OF BIRTH (Mo., Day, Yr.) August 3, 1932 14b. RELATIONSHIP TO DECEDENT wi fe 16c. DATE (Mo., Day, Yr. ) 2/1 8/201 1 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Service Gibbon, Nebraska 17b. Zip Code 68801 APPROXIMATE INTERVAL onset to death onset to death onset to death onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 14 NO 21c. WAS AN AUTOPSY PERFORMED? 0 YES XNO 9g. INSIDE CITY LIMITS xi YES ❑ NO Maiden Surname) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES ' NO 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction slte, etc. (Specify) 24b.TIME OF DEATH m 24d.TIME PRONOUNCED DEAD FEB 2 4 201I ZIP CODE 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 Title ) 25. DID TOBACCO USE I1 C RIBUTETOTHE DEATH? � 26u. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ❑ YES ' N6 ❑ PROBABLY ❑ UNKNOWN ❑ YES T( NO Not Applicable if 26a is NO 0 YES NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) �', tuft 70,n,,∎e M.D. , V1�C1e, , 0,01 Ndrcad1,0:11 (- camlZe� cinci NPbrc�.�,ci log8(�:3 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) HHS -61 11/03 (55061)