|
To Be Completed/Verified by: FUNERAL DIRECTOR
<br />1 . oacee NT8aUME (Rat. NW*, :. I.W. 006K1
<br />Maynard Albert Lif
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo,Dly.Y
<br />May 20, 2014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Bridgeport, Nebraska
<br />Si. AGE-Last Bklisday
<br />(YS.)
<br />82
<br />fib. UNDER 1 YEAR_.
<br />Sc. UNDER I DAY
<br />6. DATE OF BIRTH (MO, Day, Yr.)
<br />MOB.
<br />DAYS :.
<br />HOURS
<br />IINR
<br />October 8, 1931
<br />72 SOCIAL SECURITY NUMBER
<br />507 -32 -8315
<br />Si. PLACE OF DEATH
<br />.1N211131111.: ® IIwtiene LIM= ❑ Nursing Nom<C ❑ Hooke FaeuRy
<br />0 ERIOulpadent 0: Hems
<br />0 DOA ❑ Other(Specify)
<br />Sb.:FACIITY.NAME IX notkrtlbdion, v. .bait a and numbs)
<br />Saint Francis Medical Center
<br />lie„ CITY OR TOWN OF DEATH (fie 21p Coda)
<br />Grand Island 68803
<br />Od. COUNTY OF DEATH
<br />Hall
<br />Si. RESIDENCE - STATE
<br />Nebraska -
<br />rib. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />Sd STREET AND NUMBER ;;
<br />1214 N Howard Ave
<br />Sc. APT. NO.
<br />St 2P CODE a, S
<br />68803
<br />9g.INSIDE CITY LIMITS
<br />rffl . Vas ` ©No
<br />10e. MARITAL STATUS AT TIME OF DEATH IMO Owned ❑ New Medal
<br />0 MawNq bet ..p.r rd 0 wlaowae ❑ DlwNO•l 0 uWnawn
<br />10b. NAME OF SPOUSE (Rs*, Middle, Last Suffix) 5.11.. gM nulden n.m.
<br />Marylin Mane Ellis
<br />11. FATHER'S-NAME (FYtl,' Middle, Last, Suffix) 12. MOTHER'SNAME (Fiat, MIRES, : Malden &Im.nn)
<br />Albert C Lif Hazel McNeal
<br />13. EVER IN U.& ARMED FORCES? Gus dales of Werko If Yon
<br />Pees, No. or the.) No
<br />14a.: NFORMANT -NAME
<br />n Marie Lif
<br />14b. RELATIONSHIP TO DECEDENT
<br />S. • se
<br />16. METHOD OF DISPOSITION
<br />Mori. ❑DnW lon';
<br />0Drmullon 0 EatooNdent
<br />❑mow ❑oS..nxyao
<br />Ilia. EMBALMER- SIGNATU
<br />.IC� .1 -
<br />165. EASE No..
<br />of 'T 1
<br />16e. GATE (Na, Day, Yr.)
<br />May 24, 2014
<br />101d CEMETERY CREMA Y OR OTHER LOCATION - CITYITOWN STATE
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17.. FUNERAL HOME NAME AND WAILING ADDRESS (Strut, Ciyer Town, State)
<br />Livingston- Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />175. Zip Cote
<br />88803
<br />F To Re Completed by: CERTIFIER
<br />CAUSE OF DEATH (See Instructions and examples)
<br />14: PART L Toem tin MIMADMMI • dimmer, I,$af.,w ,mMIndowdIdedI lt,maSMIM dMIN. PO NOT afM UMW tomes sued id MORN WWII,
<br />WON* NOT ASRRRYN16.: WOW lea.. Add dd ondIlms xm..Mary.
<br />APPROXIMATE INTERNAL
<br />0014t to death
<br />ea .
<br />aop.at,yonod, r vadkudrtRAAWea wood shoal au DO d yatsaa.e.a
<br />IMMEDIATE CAUSE:
<br />geIE:AUIE1 se rso mu M 44,1eT .0 . �+ 1?
<br />DUE TO. :ORASA. • OF: to death
<br />SapwSW.fiy Oat conditions, I <' b)
<br />any, loading to the cause IRSted
<br />ondna L DUE TO, OR AS A CONSEQUENCE OF: ; otrelto death
<br />Wier the UNDERLYING CAUSE C)
<br />(dl..ma orINey that NdS.w1
<br />po' ,eems mulling in d.. . '. DUE TO, OR AS ACONSEQUENCE OF: I onset to death
<br />LAST
<br />d)
<br />16 PART a OTHER SI GNIRCANT coeWlbWng to the death but not resuitlng In the uide ying cotes given In PART I. :
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER,. TACTED?
<br />Ors D d to
<br />20. IF FEMALE:
<br />OEM prudent within past year
<br />❑Pr.gnna at thus of death
<br />0Not pregnant, but pregnard within 42 days or death
<br />❑Notpgnant, pregnant 43 days to 1 yearbetar. death
<br />n
<br />OUudaown If pregnant al net the peat year
<br />21yUA NNNER OF DEATH
<br />L�Natural ❑ HaNdd.
<br />0 Accident 0 Pending InseatIgalion
<br />❑ Surdd. ❑ Card not be determined
<br />310. F TRANSPORTATION !RIDGY
<br />: 0 DrisadOparstor
<br />: ❑ Passenger
<br />❑ Pedestrian
<br />0 Othr 1S9ecIly)
<br />21e. WAS AN AUT OP6 ED?
<br />0 YES NO
<br />210. WERE AUTOPSY FINDINGS AVARABLE
<br />E OF DEAT
<br />TO COAPLETE�CA9S N?
<br />:: ❑ : L7N0
<br />YE
<br />22a. GATE OF INJURY (Mod Day, Yr.)
<br />2Mr. THE OF INJURY
<br />m
<br />> 22c. PLACE OF INJURY -At hoen fain, sbse, teddy, office buddI g, aonauuMlon .lb. .tE. (SpsaVp)
<br />22d INJURY AT ? � 22e. DESCRIBE HOW INJURY OCCURRED
<br />0 YES NO
<br />321. LOCATION OF INJURY- STREET a NUMBER Apr. NO. CTY/TOWN STATE. ZIP COOS
<br />LL
<br />W 23b.
<br />0 .l J y
<br />230. DATE OF DEATH (Mo.. Day. Yr.)
<br />May 20, 2014
<br />� MMM
<br />J
<br />E4'ay < w
<br />24e. DATE SIGHED (Do.. Day, Yr.)
<br />24D TIME OF DEATH
<br />m
<br />DATE SIGNED (Mo., Dry, Yr.).
<br />g 28, 2014
<br />23c. TIME OP DEATH
<br />6:28 pm
<br />240. PRONOUNCED DEAD (MO.,:Dy, Yr.)
<br />210. THE PRONOUNCED DEAD
<br />m
<br />84g
<br />. O
<br />t"
<br />beat of my knowledge, death emui d at ON lime, date and piece W C
<br />due to the stead. (BUPMbas amrse) ,$z8
<br />0 1 ....-,, FO D,.
<br />24e. On the beak of exarbWlon andlor Investigation, In uy ophion Wrtb ooadrad .
<br />at* stints, dots and pta..ad due to the cause(s) can. elated. (SNgnplue and MIN
<br />26. DID , • •. „ E CONTRIBUTE THE DEATH? :
<br />❑] L NO ❑:PROBABLY ❑ UNKNOWN
<br />26s. HAS ORGAN OR TISSUE TION BEEN CONSIDERED?
<br />❑ YES NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Appasahw r25.1. NO ❑ YES (D
<br />27. „ TITLE AND ADDRESS OF CERTIFIER (Type or Pat)
<br />John A Wagoner M. D. 800 Alpha Street Grand Island Ne 68803
<br />3N REGISTRAR'S SIGNATURE
<br />d . U
<br />28b. DATE FILED BY REGISTRAR (Mo., Day. Yr.)
<br />JUN 9 2014
<br />DATE OF ISSUANCE
<br />06/11/2014
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANQk4 . V SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKAsetPARTTWEJV,T bf iiEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V� TAI, i &'Oi bS `. . ' '
<br />201501845
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />c: I+CDTIEMAATC. AC -fl ATU
<br />STANNEY S.. COOPER" ., r -, ;
<br />ASSISTANTS! TE FpEGfSTWe' "
<br />DEPA'ATAIENT i '
<br />HL41A111, SERVICES r
<br />
|