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To Be CompletedNerkkd by: FUNERAL DIRECTOR I
<br />1. DECEDENTS-NAME (Fnt, Middle, ` . Lida,. , S101x) ` .
<br />Maynard Albert Lif
<br />2. SEX '
<br />Male
<br />Sc. UNDER 1 DAY
<br />3. DATE OF DEATH (Mo..Dsy.Yr.)
<br />May 20, 2014
<br />6 DATE OF BIRTH (M•. Day. Yr.)
<br />October 8, 1931
<br />4. CRY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Bridgeport, Nebraska
<br />6a. AGE-Lest Birthday
<br />(Yes.)
<br />82
<br />60. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />507 -32 -8315
<br />Si. PLACE OF DEA111
<br />imam.; RI ktpall.nt
<br />❑ ER/Outpalrnt,..
<br />❑ DOA
<br />ones: ❑ Nu, inp Ham.A.TC ❑ Heapio■ Facility
<br />❑ Decedent's Hails
<br />❑logrr(SP•cIN)
<br />1lb. FACILITY•NAME pE not Institution, give shoat and number)
<br />Saint Francis Medical! Center ''
<br />Se. CITY OR TOWN OF DEATH ( Zip Cods)
<br />Grand Island 68803
<br />Ed. COUNTY OF DEATH
<br />Hall
<br />Ss. RESDENCEBTATE
<br />Nebraska
<br />lb. COUNTY
<br />Hall
<br />Se. CITY OR TO N
<br />{ Grand Island
<br />Ed. STREET AND NUMBER :
<br />1214 N Howard Ave
<br />9e. APT. NO.
<br />It. 22P CODE
<br />68803
<br />6g. INSIDE COY UNITS
<br />M Ya ❑ No
<br />105. MARITAL STATUS AT TIME OF DEATH ® Mused 0 Nww Marled
<br />Mewled, but separated O Widowed : Dlrurad- ❑ Unheard',
<br />106. NAME OF SPOUSE (First, Middle, Last, :Suds) Swift, glee milder' nuns.
<br />Marylin Mane Ellis
<br />11. FATHER'S -NAME (First, MIddR, : Last, SufRx)
<br />Albert C Lif
<br />12. MOTHER'S-NAME (First, Murals, M6kNn Surname)
<br />Hazel McNeal
<br />13. : EVER IN U.S. ARMED FORCES? Give dabs of aarNSe If Yss.
<br />(ra.. Na or MIL) No
<br />11a. INFORMANT-NAME
<br />Marylin Marie Lif
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF. DISPOSITION
<br />°.uo„
<br />®"" ❑o.
<br />❑Crra+oe ❑ EAtImiddent
<br />❑Ri110ti .. ❑ ry1
<br />16e. EMBBALM SIDNATU
<br />dilatlr'iIL
<br />16b. ENSE NO. I II
<br />/ i
<br />: 1de. DATE /IM., Day, Yr.)
<br />May24, 2014
<br />16d. CEMETERY ' OR OTHER LOCATION : CITY/TOWN STATE
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />174. FUNERAL HOME NAME AND MJULEIG ADDRESS (Elbeet. City or Town. Stets) :
<br />Livingston- Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />170. ZIP Cods
<br />68803
<br />tA,/ To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />1c PAW L Tastes rhMi¢sLmdit.di. em,lej•w,«eass OW a acrd Me ern: PO NOT .nwtawM .r+rnsdum asrwrs. ;. ;; APPROXIMATE INTERVAL
<br />PAW only Add AMAMIMra
<br />rnrwrrr+n r, or vdedkulteedllIdllon widr dhavoins Br Wragr. DO Nor AIUNNUA1e. ow nu.. MOM.
<br />IMMEDIATE CAUSE: [ : onset to lath
<br />°,g O E CAI0E (Ward ' - _ o - y 9 J CJ II!�( -�1J /...
<br />tg � «arrdWNrar •) s Q ✓yv ��////
<br />DUE TO. OR AS A • • SEQUENCE OF: - I onset to dealt
<br />6p1rn°allyOa conditions, If °)
<br />any,, leading to the aw
<br />on rkn s. DUE TO, OR AS ACONSEQUEE OF: I
<br />NC onset to dear
<br />Enter get UNDERLYING CAUSE a) :. I
<br />(dew= or Injury thus k6tlatad
<br />DUETO, OR ASA CONSEQUENCE OF: : onset to death
<br />Sr► Nanb ',MIN. b daatlr) 1
<br />LAST
<br />d)
<br />IS. PART U OTHER SIGNIFICANT CONDMONS4ondtlIons anetbudngto the dada but not rsetilrtg Inge underlying caves ghat In PART I.
<br />16. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES y / NO
<br />20. F FEMALE:
<br />01405 prsgnsnt sithin past yaw
<br />DPragant.rtNtns er dSslh
<br />❑Not prsu an but pregnant within 42 days Orissa
<br />❑Nat pregnant but pregnant . u days to t year War, :death
<br />Dur+•rwn If pregnant within the past year
<br />21 NOR OF
<br />I Natural ❑Honudds
<br />DEATH
<br />Pending trrveegpauon
<br />Codd not a determined
<br />216. F TRANSPORTATION INJURY
<br />':❑OrwsNOparatcr
<br />: ❑ Passenger
<br />❑ Pedestrian
<br />' ❑ Mar (SP•lty)
<br />21e. WAS AN AUTOPBEDT
<br />❑ YES NO
<br />❑ Aeddat ❑
<br />❑ !Wield* ❑
<br />21d. WERE AUTOPSY FINDINGS AVAI AVAILABLE
<br />TO COMPLETE CCA SEOF DEATH?
<br />El ves : Irmo
<br />22.. DATE OF AWRY (Mo, Day. Yr.)
<br />226. TIME OF EJURo
<br />m
<br />22c. PLACE OF INJURY -At hones. fret West faetory, *TRA. Strp ansr tellen sled, see. (Spaeth)
<br />22d. INJURY AT •?
<br />❑ YES FJNO
<br />226. DESCRIBE HOW INJURY OCCURRED
<br />rd. LOCATION OF INJURY - STREET 6, NUMBER, APT. NO. : CITY/TOWN STATE ZIP CODE
<br />W
<br />K
<br />61. �
<br />er t`
<br />G G
<br />Zan. DATE OF DEATH (Ma. Dhy. Yr.)
<br />May 20, 2014
<br />a tttppp
<br />1 0 }
<br />�w <�
<br />A l W
<br />= Op
<br />ti b
<br />24a. DATE SIOI Pao.. Dey. Yr)
<br />9 TWEOF DEATH
<br />m
<br />22b, DATE SIGNED (Mo., Day, Yr.)
<br />28, '2014
<br />23e. TRIO OF DEATH
<br />6.28' pm
<br />21e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />E POUNC DEAD
<br />24d. TM E1
<br />m
<br />beat my ktades, Waal occurred at Wed Bra an
<br />a wN . data d place
<br />due to get stated. (6lgnebas and nil.)
<br />doom oaad
<br />24e. On the WIN* of wwwinsgen anew Imadgsden, In m y opinion at
<br />at lied tired, data r es d plate and d to Its eauss(s) gated. (Buda bbs and TAW)
<br />2 A - MD , • • „ E CONTRIBUTE • THE DEATH?
<br />II NO ❑.PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE • • TDN BEEN CONSIDERED?
<br />;. ❑ YES w NO
<br />alb. WAS CONSENT GRANTED?
<br />Na Applicable N 26a M NO ❑ YES ` aI4
<br />27. ;: TITLE AND ADDRESS OF CERTIFIER (Typo or Pia) ..
<br />John 'A Wagoner M.D. 800 Alpha Street Grand Island Ne 68803
<br />tea. REGISTRAR'S SIGNATURE
<br />`
<br />26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JUN 9 2014
<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 flE'P4RTM,ENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECQROS,t
<br />DATE OF ISSUANCE
<br />06/11/2014
<br />LINCOLN, NEBRASKA
<br />201500935
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE
<br />(:FRTIFICATF'(W l ATH
<br />R
<br />STANLEY S. COQQER ?: -
<br />A &SISTA TATE REGISTRAR''.
<br />DEPARTM 1O E 1LTH 1�1Ib;
<br />',HyMtrIN C`E •
<br />84
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