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9a. RESIDENCE -STATE Nebraska 28a. REGISTRAR'S SIGNATURE 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 RECQRD -ON F�C� THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI, ICSSEIVQ1, V,I1L?i� 08070 THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE MAY 3 0 2007 LINCOLN, NEBRASKA 9d. STREET AND NUMBER 1203 West Anna Pauline Angela Braun 9f. ZIP CODE 68801 10a. MARITAL STATUS AT TIME OF DEATH 52 Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife give maiden name. ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, 9g. INSIDE CITY LIMITS Xi YES ❑ NO Robert James Suffix) 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. 14a. INFORMANT -NAME (Yes, no, orunk.) No Pauline James 12. MOTHER'S -NAME (First, Middle, Sarah 16b. LICENSE NO. 3taa Maiden Surname) Kirley 14b. RELATIONSHIP TO DECEDENT Wife 16c, DATE (Mo., Day, Yr. ) Ma 7 2007 15. METHOD OF DISPOSITION %Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OT ERLOCATI• CITY / TOWN 17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 West Second, Grand Island, NE. STATE Westlawn Memorial Park Cemetery Grand Island, Nebraska 17b. Zip Code 68801 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 it necessary IMMEDIATE CAUSE: 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 22d. INJURY AT WORK? ❑ YES ❑ NO (a) t-1 T DUE TO, OR AS A CONSEQUENCE OF: (b) DUE TO, OR ASA CONSEQUENCE OF: (c) DUE TO, OR AS A CONSEQUENCE OF: (d) 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.) 21a. MA ROF DEATH Natural ❑ Homicide ❑ Accident❑ Pending Investigation ❑ Suicide ❑ Could not be determined THAI Lvr�:c 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 5- CA tEM �`zO \ I tt - Tree . U s M, G� 21b.IFTRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) APPROXIMATE INTERVAL onset to death IA N yuu onset to death onset to death onset to death 19. WAS MEDICAL EXAMINER OR CORONER CO ED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? 22b. TIME OF INJURY m 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. ❑ YES NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? CJ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) CrTY/TOWN STATE ZIP CODE 23a. DATE OFDE•TH (MT, Day, Yr.) 23b. DATE SIG • ED (f4tr., Day, Yr.) 5 ' 23d.Tothe •- R.,1 anf 16a. EMBALMER- SIGNATURE 23c. TIME OF DEATH d.-,. -.t u -..it -11 -,. dplace e s stated. (Signature and Title . DIDTOBACC• uECONTRIBUTE TO THE DEATH? ES ❑ NO ❑ PROBABLY Ll UNKNOWN 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 24a. DATE SIGNED (Mo., Day, Yr.) a U_Z y0 d =G aaaz m E ¢ F p ° w z 24e. On the basis of examination and /or investigation, in my opinion death occurred at o o the time, date and place and due to the cause(s) stated. (Signature and Title) • 0 o 26a. HAS ORGAN OR TISSUE _ DONATION BEEN CONSIDERED? ❑ YES 1110 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 1. DECEDENT'S -NAME (First, STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE ANDSUP CERTIFICATE OF DEATH Middle, Last, Lewis Cornelius James 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Paxton, Nebraska 7. SOCIAL SECURITY NUMBER 505 -18 -6137 8b. FACILITY -NAME (If not institution, give street and number) Bergan Mercy Hospital 8c. CITY OR TOWN OF DEATH (Include Zip Code) Omaha 9b. COUNTY Hall 5a. AGE -Last Birthday (Yrs.) 4,489 Suffix) 5b. UNDER 1 YEAR MOS. DAYS 9c. CITY OR TOWN Grand Island 9e. APT. NO LEY S: DOPER ASsISr rSTATEE#?EGISTRAR HEALTH AND HUMAN SEA#JCES 2. SEX Male 5c. UNDER 1 DAY HOURS 8d. COUNTY OF DEATH Douglas 25903 3. DATE OF DEATH (Mo., Day, Yr.) May 3, 2007 6, DATE OF BIRTH (Mo., Day, Yr.) MINS. March 7, 1918 8a. PLACE OF DEATH HOSPITAL: X Inpatient OBBER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER /Outpatient ❑ Decedent's Home ❑ 0.4 ❑ Other (Specify) 24b.TIME OF DEATH MAY 2 5 200? m 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) - rlr1 ePe 44741,-.7 / "7.-z / •, / _ . J . i //. l/• /9/2 /. %s [ / "'A oAf4 t f 6, 9/ 3o hy) 28b. DATE FILED Bf' REGISTRAR (Mo., Day, Yr.)