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1. DECEDENT'S -NAME D Middle, Last, Duane Evans Suffix) 2 SEX ale' Febtua 2r) :• �� 208 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Ansley, Nebraska 5a. AGE Birthday (Yrs.) 79 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (4o., Day, Yr.) March 14, 1928 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -30 -8970 8a. PLACE OF DEATH HOSPITAL: $I Inpatient M 5. ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER /Outpatient ❑ Decedent's Home ❑ 1704 ❑ Other (Specify) 8b. FACILITY•NAME (It not institution, give street and number) St. Francis Medical Center 8m CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE STATE Nebraska 9b. COUNTY Hall 9m CITY OR TOWN Grand Island 9d. STREET AND NUMBER 4115 W. Airport Rd, 9e. APT. NO 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ❑ YES i1 NO 10a. MARITAL STATUS AT TIME OF DEATH 51 Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife give Malden name. Eunice Kohls 11. FATHER'S-NAME (First, Middle, Last, Suffix) Cyrus Evans 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Annis Deal 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. (Yes, no, orunk.) No 14a. INFORMANT -NAME Eunice Evans 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION Burial ❑Donation 16a. EMBALMER- SIGNATU ,,,...1 lab. LICENSE NO '�/32s� 16c. DATE (Mn ., Day, Yr. ) February 16, 2008 ❑ Cremation ❑ Entombment ❑Removal Other(Specify) 16d. CEMETERY, CREMATO OR OTHER LOCATION CITY / TOWN STATE Litchfield Cemetery Litchfield, Nebraska 17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 West Second, Grand Island } " 18. PART I. Enter the chain of events - diseases, injuries, or complications -•that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE 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: I onset IMMEDIATE CAUSE (Real (a) CO ill wevJ1 4 AJC(A/t al 1 1 , 1 4 (91L# 17b. Zip Code 68801 INTERVAL to death /1( " disease or condition mulling DUE TO OR AS A in death) Sequentially Hat conditions, M @1 leading C NSEOUENCE OF 1 91 &4 2 I onset to death I �i, 1t �.d_P GU G I '?II ?... any to the cause listed DUE TO OR on line a. Enter the UNDERLYING CAUSE (disease or injury that Initiated (c) CONSEQUENCE OF I onset to death I - I I the events resulting In death) DUE TO, OR AS A CONSEOUENCE OF: I onset to death LAST (d) 18. P / �� T II.00T SIGNIFICANT CONDITIONS Conditions contributing to the death but not resulting in the underlying cause given in PAR I. 1 11 rV1 010/1.4)a; bem19I 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES Ail NO 20. IF FEMALE ❑ Not pregnant within past year ❑ 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 pregnant within the past year 21a MANNER OF DEATH Natural ❑ Homicide ❑ Accident❑ Pending Investigation ❑ Suicide ❑ Could not be determined- 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑Passenger ❑ Pedestrian ❑ Other ( Speciy) 21c WAS AN AUTOPSY PERFORMED? ❑ YE3NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES 51 NO site etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22m PLACE OF INJURY -At home, term, street, factory, office building, construction 22d INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22t LOCATION OF INJURY - STREET & NUMBER, APT. NO CITY /TOWN SIAIt ZIP CODE 2< 1y EEz E ,81 o 2 r 23a. DATE OF DEATH (Mo., Day, Yr.) 01 - 1 3 -.04 _ 24a. DATE SIGNED (Mo., Day, Yr.) sW Z 246. TIME OF DEATH 23b. DATE - SIGNED Mu.,Da r.) t7 -/ ' - o d 23m TIME OFDEATH 3. LJ Ism If1 24c.PRONOUNCEDDEAD(Mo.,Day,Yr.) a z 24d. TIME PRONOUNCED DEAD m 23d. To the best of my knowledge, death occur ed at the time date and place 8 cc 0 24e. On the basis of examination and /or investigation, in my opinion death occurred at and due to the cause(s stated. (Signature and Title) • ♦ o 1 p the time date and place and due to the cause(s) stated. (Signature and Title) V 25. DID TOBACCO USE CONTRIBUTETOTH EATH? ❑ YES 41 NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES JeNO 28b WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Richard Fruehling M.D. 2116 W. Faidley Ave. Grand Island, NE 68803 28a. REGISTRAR'S SIGNATURE • � 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) FEB 2.5 2008 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE FEB_ 2 7 2008 LINCOLN, NEBRASKA 201502185 ASSIST/LW HEALTHY STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE 4 BUP HHS-61 11/03 (55061)