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DATE OF ISSUANCE JAN S 9 2010 STATE OF NEBRASKA • 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 DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL stECORDS... 201506989 STANLEY S. COOPER A SS. %S rA N T ' STATE REGISTRAR DEPART.4ENT OFWEALTH AND LINCOLN, NEBRASKA HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES' iI i fr: t 2 05&t CERTIFICATE OF DEATH 3 DATEIORDEATH (Mo.,Day, 'r.) January 19, 2010 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Allen Wilber Tucker 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH St. Paul, Nebraska 7. SOCIAL SECURITY NUMBER 506 -32 -8165 Bb. FACILITY -NAME (If not Institution, give street and number) Wedgewood Care Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand island 68803 9a. RESIDENCE-STATE Nebraska 9d. STREET AND NUMBER 1214 Plantation Place 10a. MARITAL STATUS AT TIME OF DEATH IX1 Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown eti v m 13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes. 0 I- (Yes, No, or Unk.) Yes 06/21 /1945- 02/05/1946 11. FATHER'S -NAME (First, Middle, Last, Suffix) Tracy Tucker 16. METHOD OF DISPOSITION ❑Burial ❑Donation ®Cremation ❑Emombmem ❑ Removal ❑Othegapeeity) (disease or Injury that Initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: LAST 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 ft pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? ❑ YES ❑ NO 28a. REGISTRAR'S SIGNATURE 9b. COUNTY Hall 16a. EMBALMER-SIGNATURE Not Embalmed 22b. TIME OF INJURY m 5a. AGE-Last Birthday (Yrs.) 85 14a. INFORMANT-NAME Bernice Tucker 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 23a. DATE OF DEATH (Mo., Day, Yr.) o ( - (� i - Zo(L 23b. DATE SIGNED (Mo., Day, Yr.) 6÷-4-9-441001 - - lie° 23c. TIME OF DEATH q t t/V �' m 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) fit" 26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONA ❑ YES tif NO ❑ PROBABLY ❑ UNKNOWN ❑ YES lif NO 5b. UNDER 1 YEAR MOS. DAYS HOURS 8a. PLACE OF DEATH fiOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA OTHER: El Nursing Home/LTC ❑ Hospice Facility ❑ Decedent's Home ❑ Other(Specify) 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 9e. APT. NO. 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) I wife, give maiden name. Bernice Tagge 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) Edna Deininger 16b. LICENSE NO. 2. SEX Male 6c. UNDER 1 DAY MINS. 8. DATE OF BIRTH (Mo., Day, Yr.) December 6, 1924 9r. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® Yes ❑ No 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) January 21, 2010 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY/TOWN Gibbon STATE Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 1e. PART I. Ether the chain of events - diseases, injuries, or complications- that directly cawed the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final - ` , disease or condition resulting a) t . / a �j+ `jAAWV4(i In death) APPROXIMATE INTERVAL onset to death A day, DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, If b) at-77'4/11N 7' any, leading to the cause listed onset to death 'etU d on line a. Enter the UNDERLYING CAUSE c) DUE TO, OR AS A CONSEQUENCE OF: onset to death d) onset to death 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the undedying cause given in PART L lfaA %P %o $lam 4/4 ` M' rrkku etfr CkM 4A t1 A444 ct, 21b. IF TRANSPORTATION INJURY ❑ Driver/operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 12 NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, fans, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH m 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 1 24d. TIME PRONOUNCED DEAD 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 1111e) ON BEEN CONSIDERED? 28b. WAS CONSENT GRANTED? Not Applicable If 28a is NO ❑ YES a NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Anne K. Morse, M.D. 729 N. 729 N. Custer Ave., Grand Island, NE 68803 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) JAN 2 7 2010 1