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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES; IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEP. I TENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL;R.4p DATE OF ISSUANCE JUL 31 2008 LINCOLN, NEBRASKA 1. DECEDENT'S -NAME (First, Eugene 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 506 -46 -0388 8b. FACILITY -NAME (If not institution, give street and number) St. Francis Medical Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island, 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 405 West Stolley Park Road 10a. MARITAL STATUS AT TIME OF DEATH (XMarried ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Thomas 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. (YeSp,'r�6,1�'if'unk-J /31 /1957 5/30/1961 15. METHOD OF DISPOSITION laBurial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 175. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 West Second, Grand Island, NE. 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, 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) CBordeteJla brovickiserf'-a IMMEDIATE CAUSE (Final disease or condition resulting In death) Sequentially list conditions, If any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or injury that initiated the events resulting in death) LAST (b) (c) (d) 18. PART II. OTHER SIGNIFICANT CONDITIO Conditions contributing to the d th but not resulting in the underlying use even in PART I. acrk.$e t-en a oti 'Li re- r , aeu pa prat :z a u r2.. 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 22a. DATE OF INJURY (Mo., Day, Yr.) Middle, 23a. DATE OF DEATH (Mo., r v/� o., Day, Yr.) �N.G rV / , 8 DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: 22d. INJURY AT WORK? ❑ YES ❑ NO 221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. 22b. TIME OF INJURY m 22e. DESCRIBE HOW INJURY OCCURRED iu mD 25. DID TOBACCO USE CONTRIBUTE TOTH EATH? 28a. REGISTRAR'S SIGNATURE 201502300 ,..v r _ STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEROFCES'FINAr GE i' D -§I CERTIFICATE OF DEATH Q8 7` 5 Middle, Last, Suffix) ' 3s'ATEOFDEAT o., Day, Quentyn Watson 9b. COUNTY Hall STATE OF NEBRASKA Last, Watson Suffix) 14a. INFORMANT -NAME Judith Watson 16a. EM; LMER - SIGNATURE 4 ! ✓. . 16.. CEMETE • CREMATORY OR 0 ER LOCATION Westlawn Memorial Park Cemetery Grand Island, NE 21 a. MANNER OF DEATH Q}•latural ❑ Homicide 23d. T. the best of my knowledge, death occur ed at the time, date and place and due the cause(s) stated. (Signature and Title) • 5a. AGE -Last Birthday (Yrs.) 68 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. ❑ Accident Pending Investigation ❑ Suicide ❑ Could not be determined CRY/TOWN 1 Si 23b. DATE SIGNED (Mo., Day, Yr.) 23c.TIME OF DEATH Wo (/ � • m o2Z S = 0 2 C 0 0 5b. UNDER 1 YEAR MOS DAYS 9c. CITY OR TOWN Grand Island 12. MOTHER'S -NAME (First, Alyce STAPII Y S. COOPER ASSISTA1VF STATE REGISTRAR DEPARTMENTW EALT,H AND HUMAN 2, SEX male HOURS 8d. COUNTY OF DEATH Hall Judith Lukesh 16b. LICENSE NO. 45.28 CITY /TOWN i'neM vNO ) a.. 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 5c. UNDER 1 DAY YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES 7e.r 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, MINS 9f. ZIP CODE 68801 Middle, 'July 19, 2008 6. DATE OF BIRTH (Mo., Day, Yr.) November 22, 1939 8a. PLACE OF DEATH HOSPITAL: a Inpatient QTEBT}J : ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ COA ❑ Other (Specify) ❑ YES 4NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr. ) July 23, 2008 STATE 24b. TIME OF DEATH 26b. WAS CONSENT GRANTED? NE 68803 9g. INSIDE CITY LIMITS II YES ❑ NO Maiden Surname) Pounder 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 AL NO 21c. WAS AN AUTOPSY PERFORMED? 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES VICNO STATE ZIP CODE 24d. TIME PRONOUNCED DEAD m 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) • Not Applicable if 26a is NO ❑ YES, NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) JUL 2 9 2008