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<br />STATE OF NEBRASKA
<br />WHEN > THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OFISSUANCE
<br />02/23/2016
<br />• LINCOLN NEBRASKA
<br />CEDE NT& -NAME (First, Middle, Last, Suffix)
<br />Jlliam Dean Mefford
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hastings, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />605-364422 _., ..
<br />6b: FACILITY -NAME (If not Institution, give street and number)
<br />a Veterans Affairs Medical Center
<br />tic. CITY QR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />u.
<br />LL
<br />Oa. RESIDENCE -STATE
<br />Nebraska
<br />t. S TREET AND NUMBER
<br />2415 Lamar Ave
<br />15. METHOD OF DtSPO8fr1ON
<br />,;Dome. '_. ❑DoMian
<br />� DraetaBon ❑Emonb.m
<br />: .�R•nevtl -- ❑OtMdep•ctry)
<br />I PART
<br />22d. INJURY. AT WORK?
<br />❑ YES ❑ NO
<br />d)
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />lib. COUNTY
<br />Hall
<br />Ilia, EMBALMER - SIGNATURE
<br />Not Embalmed
<br />20. IF FEMALE:
<br />] ?lot p» Year
<br />I. et thns of death
<br />°Not pregnent,but pregnant within 42 days of death
<br />. ❑Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unknown if pregnant within the past year
<br />E
<br />DATE OF INJURY.. (ma , Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />WD TOt}/i o USE C TB TO THE DEA
<br />]YES O : l \' - BLY ❑ UNKNOWN
<br />27; NAME TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />20
<br />DATE SIGNED (Mo., Day, Yr.)
<br />23a. DATE. OF DEATH. (Mo., Day, Yr.)
<br />othebest
<br />and due to
<br />ST 'g SIGNATURE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />21d. WERE AUTOPSY FINDINGS AI/AI
<br />TO COMPLETE USE OF DEATHS
<br />STATE ZIP CODE
<br />24b. TIME OF DEATH
<br />1ga. MAR1:1'AL AT TIME OF DEATH ® Married ❑ Never Married id, NAME OF SPOUSE (First. Middle, Last, Suffix) N wife, give maiden name.
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />Esther Rose Hoff
<br />11 FATHER'S -NAME (first, Middle, Last, Suffix)
<br />Carl Allen Mefford
<br />EVER IN U.S.. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME
<br />ffes, No, or Unil-) Yes 0510111951- 0713111973 Esther Rose Mefford
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />lie. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />It PART I. Ester the StaidELSSittl . dim..., injuries, or canpBeaasn -tut directly caused the death. DO NOT enter tenantl events such as Cardiac arrest,
<br />reephatoy am t, or ventricularnbdladIon without sheaving the etiology. DO NOT ABBREVIATE. Enter only one eau. on • Ens. Add additional lines if Mcasa.ry.
<br />IMMEDIATE CAUSE:
<br />DOER SIGNIFICANT CCNDmONS- Condltona contributing to the death but
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22c. PLACE OF
<br />STREET & NUMBER, APT. NO. CITY/TOWN
<br />my knowledge, death occurred at the time, data and place
<br />cause(s) stated. (Signature and Tide) ...
<br />Sa. AGE -Last Birthday
<br />(Yrs.)
<br />81
<br />Eb. UNDER 1 YEAR
<br />MOS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL: Inpatient
<br />--1 ERIOutpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />IMMEDIATE CAUSE (Final
<br />disease of condition multi ■
<br />in death) molting ) \^4 � 1tiit4.l�\
<br />DUE TO, OR AS CONSEQUENCE •
<br />Sequentially list conditions, If (y
<br />any, leading to the cause listed D ) \' \ ("ear k l` � \ \ S U (\
<br />online a, DUE TO, OR AS A CONSEQUENCE OF:
<br />Entpr the t LYNG AUSE c). C Q Ct r1 C
<br />1 �A �1� l ptl
<br />(dMdaeeerin C d'
<br />the ev re in death DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />21a. MANNER OF DEATH
<br />'iaturat 0 Homicide
<br />❑ Accident J Pending tnvestigatfon
<br />❑ Suicide ❑ Could net be delemdned
<br />INJURY
<br />DAYS
<br />tilting in the:undertying cause given In PART L
<br />STANLEY S. '• OPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />CERTIFICATE OF DEATH - 29724
<br />2. SEX
<br />tab. LICENSE NO.
<br />Male
<br />6c. UNDER 1 DAY
<br />HOURS
<br />OTHER ❑ Nursing HomeILTC ❑ Hosptee F
<br />n Decedent's Home
<br />❑ OthenSpeclry)
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Ethel Delilah Swin • le
<br />MINS.
<br />64. COUNTY OF DEATH
<br />Hall
<br />CITY/TOWN
<br />Gibbon
<br />9f. ZIP CODE
<br />68803
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />C1 Passenger
<br />Q Pedestrian
<br />❑ Other (Specify)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />3. DATE OF DEATH (Mo.,DAy,Yr.)
<br />December 29, 2013
<br />8. DATE OF BIRTH (Mo., Day, Yr)
<br />April 29, 1932
<br />9g. INSIDE t;i.TY Li
<br />gi Yes Q` N
<br />14b. RELATIONSHIP TO DECEDENT?
<br />Wife
<br />164. DATE (Mo., Day, Yr.)
<br />January 1, 2014
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />onset to death
<br />onset to death
<br />onset to dent
<br />19. WAS MEDICAL E.7fAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES bi NO
<br />31c. WAS AN AUTORY PERFORMED?
<br />❑ YES NO
<br />home, farm street, factory, office building, construction site, etc. (Specify)
<br />ert'
<br />24e. O the basis of examination and/or investigation, In my opinion deatt queened
<br />at the tine, date and place and due to the cause(s) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE ORATION BEEN CONSIDERED?
<br />❑ YES NO 26k. WAS CONSENT GRANTED?
<br />- Not Applicable If 26a le NO ❑ YES
<br />28b. DATE FILED BY REGISTRAR (Mo., Dey Y
<br />JAN 6 2014
<br />STATE
<br />Nebraska
<br />I 17b. Zip Code
<br />68801
<br />•
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