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1. DECEDENT'S -NAME (First, Edward WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTHAND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE CORY OF THE ORIGINAL RECORD-ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS-SECTION, WH%LIS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE SEP .0 .9 2005 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT -. CERTIFICATE OF DEATH G5 p 9 p 7 1 8c. CITY OR TOWN OF DEATH (Include Zip Code) Wood River, 68883 9a. RESIDENCE -STATE [Nebraska 9d. STREET AND NUMBER 307 West 9th St. 19b. COUNTY Hall 10a. MARITAL STATUS AT TIME OF DEATH Ni Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Floyd 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. 14a. INFORMANT-NAME (Yes, no, or unk.) NO 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation 181 Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a EMBALMER-SIGNATURE Not embalmed Alice Murphy Alice Junker Central Nebraska Crem. Serv. 9c. CITY OR TOWN Wood River 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) A•fel Funeral Home 411 W. 11th P.O. Box 126 9e. APT. NO 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68883 1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Middle, Last, Suffix) 12. MOTHER'S -NAME (First, E. Junker Elizabeth 16b. LICENSE NO. 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN Middle, M . 9g. INSIDE CITY LIMITS 51 YES ❑ NO Maiden Surname) Lehn 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr. ) September 2, 2005 STATE Gibbon Nebraska 17b. Zip Code Wood River NE 68883 18. PART 1. 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: IMMEDIATE CAUSE (Final disease or condition resulting In death) Sequentially Ilst conditions, If any, leading to the cause listed on Inc I a. Enterthe UNDERLYING CAUSE (disease or Injury that Initiated the events resulting In death) LAST ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ No1 pregnant, but pregnant within 42 days o ik eath ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 22a. DATE OF INJURY o., ay, Yr.) 23d. To the b sl of my kn and due • lhe cause (a) LAR 1O ry, pratioR- QYLIQkt' DUE TO, OR AS A CONSEQUENCE OF: (b) maueIrlartt PlavautP uKf, DUE TO, OR AS A CONSEQUENCE OF: ( r LuV1.C1 Ca .n cE1K DUE TO, OR AS A CONSEQUENCE OF: (d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. r Q &01 Q4 20. IF FEMALE: 21a. MAN b. TIME OF INJURY m SCRIBE HOW INJURY OCCURREq 22d. INJURY AT WORK? ❑ YES ❑ NO 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT. NO. R OF DEATH atural ❑ Homicide ❑ Accident❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger 14 ❑ Pedestrian ❑ Other (Specify) APPROXIMATE INTERVAL onset to death onset 10 death onset to death onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES Tor SY NO '21 d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home farm, street - : ctory . lice building, construction site, etc. (Specify) CITY/TOWN r\A STATE ZIP CODE E d Z 0c° f` t- 23b. (_JI SIGNET ('l ay, Yr.) Y led ) st 23c. TIME OF DEATH 5 ' /4,m , death occur ed at the time, date and place et. (Signature and Title ) Y/ 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES • 0 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) • WAS CONSENT GRANTED? t Applicable if 26a Is NO ❑ YES ❑ NO 25. DID TO CCO USE C . NTRIBU ETO THE DEATH? YES ❑ NO it PROBABLY ❑ UNKNOWN 27. NAME,TITL ND ADDRESS OF CERTIFIER (PHYSICIAN, ORONER'S PHYSICIAN 0 908 N. Howard St.#1 rand Island NE 68 FILED BY REGISTRAR (Mo., Day, Yr.) 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH McCook, Nebraska 5a. AGE -Last Birthday (Yrs.) 73 7. SOCIAL SECURITY NUMBER 506 -28 -6460 813. FACILITY -NAME (If not institution, give street and number) 307 'Waist 9th Street 23a. DATE OF DEATH (Mo., Day.Yf.)q 1 n / Q 7" 5b. UNDER 1 YEAR MOS OUNTY ATTORNEY (T PF r 4 DAYS 50. UNDER 1 DAY HOURS MINS 8a. PLACE OF DEATH HOSPITAL: ❑ Inpatient OTHER: ❑ ER /Outpatient ❑ Nursing Home /LTC ❑ Hospice Facility la Decedent's Home ❑ Other (Specify) 24a. DATE SIGNED (Mo., Day,Yr.) 24c. PRONOUNCED DEAD (Mo., Day,Yr.) 24b.TIMEOF DEATH m 24d. TIME PRONOUNCED DEAD m 28a. REGISTRAR'S SIGNATURE DATE SEP =7 2005 3 1931 Middle, J. STATE OF NEBRASKA 201506'765 Last, Junker Suffix) if TANLEY .= COOPER ASSISTANT STATE REGISTRAR HEALTH AND HUMAN-'a VICES 2. SEX Male September.'2, 2005 a.. DATE OF DEATH (Mo., Day, Yr.) 6: DATE OF BIRTH (Mo., Day, Yr.) 8, 03