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STATE OF NEBRASKA
<br />iaM
<br />t18
<br />14
<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 OF ISSUANCE
<br />2/22/2016
<br />LINCOLN, NEBRASKA
<br />F
<br />LL
<br />1. (Fast, Middle, Last. Saul
<br />Mary Lou June Hammond
<br />4 CITY
<br />AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />Hooper, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508 - 364453
<br />6b. FACILITY -NAME (It not WMltulion, give street and number)
<br />CHI Health St. Elizabeth
<br />Se, OITY OR TOWN OF DEATH (Include Zip Code)
<br />Lincotn 68510
<br />94 RESIDENCE-STATE
<br />Nebraska
<br />STREET AND-NUMBER
<br />100 MI Valley Drive
<br />16a MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married
<br />❑ Married, but separated 5 widowed ❑ °Wonted ❑ Unknown
<br />11 FRTHER $ -NAME (FirM, &SOON, Last, Suffix
<br />L We'man
<br />13. EVER RS U.S. ARMED FORCES? Give dates of service H Yes. (144 INFORMANT -NAME
<br />(Yoe, No, or Unk) No
<br />16.E YETHODOF: DISPOSITION
<br />tliturrai ottenstion
<br />ISICNmWon ! ❑Eabrsbm -M
<br />0Ramo0a! ❑CnwrfsPerav)
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfei Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />MAMEDIATE OA4SB:
<br />risetse osolMlt)liti resulting a)
<br />in death) •
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, I
<br />open, leading 505*. cause listed
<br />Itne 4 ......:: >.
<br />NG CAUSE 0)
<br />(ditittae or Infra) that Waited
<br />the events resulting in death)
<br />LAST
<br />1 e: ?PART 6.4TNER SIGNIFICANT CONDITION$ - Conditions contributing to
<br />Houses Fire
<br />26,,15 FEMALE:
<br />Pr'rgl MAtNn Put yea
<br />❑wynY+t,et did of death
<br />❑trot preprla nt, but pregnant within 42 days of death
<br />0Not pregnant. but pregnant 43 days to 1 year before dealt
<br />❑unknown if pregnant within the pat year
<br />DATE OF INJURY (Mo., Day, Yr-)
<br />12 - 20-15
<br />22d. INJURY AT WORK?
<br />Els
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />164 EMBALMER-SIGNATURE
<br />Not Embalmed
<br />164 CEMETERY, CREMATORY OR OTHER LOCA
<br />BAIL Cremation Service
<br />Smoke inhalation
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Burns
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />House Fire
<br />9b. COUNTY
<br />Hall
<br />INJURY - STREET & NUMBER, APT. NO.
<br />1007 Sun Valley Drive
<br />22b. TIME OF INJURY
<br />Unknown m
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />1 1 , 1 10
<br />SIGNED (Mo., Day, Yr.) 23c, TIME OF DEATH
<br />t 11,1A k,
<br />2016017-3.3
<br />.
<br />23d To the bat of my knowledge, death occurred at the lime, date and piste
<br />and did to die cause(*) Metal . (StgneWre and Tide)
<br />9r AGE.LeetBirtday
<br />(Yrs.)
<br />79
<br />6b. UNDER .1 YEAR
<br />MOS
<br />tie. PLACE OF DEATH
<br />tl ® Inpedar*
<br />❑ ERAOutpatie,d
<br />0 DOA
<br />9a CRY OR TOWN
<br />Grand Island
<br />10b. NAME OF SPOUSE (First, Middle,
<br />Richard F Hammond
<br />1 2. MOTHER'S-NAME (First, Mldae,
<br />Florence Hankins
<br />David Hammond
<br />death but Glut
<br />22c. PLACE INJURY-A
<br />Home'
<br />21a. MANNER OF REATH -.
<br />"lgtatrrel 0 Honriide
<br />Accident ❑Pen40Qknv our
<br />❑ snnlek. ❑Card not be determined
<br />$ oo
<br />O
<br />Uwu
<br />CITWTOW N
<br />Grand Island
<br />DAYS
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />2. SEX
<br />165. LICENSE NO.
<br />Lincoln
<br />CAUSE OF DEATH (See Instructions' and examples)
<br />14. PART L Wet tee eb0M Drama . diseases, Slobs. or cmapMCanonaMat Noway caoaed do *WA DO NOT sass bmWW events sash as congas anon,
<br />respiratory soya, or sourStalsr OerMrlo,r *Mod shaving OW etiology. 00 NOT ABBREVIATE. Endr only ono owes on a tins. Add edesbnen NO. It neoesxrs.
<br />_..... .. _. IMMEDIATE CAUSE:
<br />] „{ Passenger
<br />©>Pedestrian
<br />❑ othof (SPotifY)
<br />Female
<br />6c. UNDER 1 DAY
<br />HOURS
<br />244 DATE SIGNED Intro., Day, Yr.)
<br />MINS.
<br />❑ Nursing Homen.Tc
<br />❑ Decodenrs Hone
<br />❑DINN Speelry)
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />APT. NO. W.2' CODE
<br />68801
<br />set, Suffix) I write, give maiden name.
<br />CITY/TOWN
<br />undwtyieg saute given in PART L
<br />21h. IF TRANSPORTATION INJURY
<br />farm. 'Meet _factory, office building. construction its, etc.
<br />Nebraska
<br />INNSANDICED DEAD Leto•, Day, Yr.)
<br />Coe
<br />16 20386
<br />3. DATE OF DEATH (Mo.,
<br />January 21, 2016
<br />Yt.)
<br />6. DATE OF BIRTH (Mo., Day,
<br />Maiden Surname)
<br />140. REIATIONSNIP TO DECEDENT
<br />Son
<br />160. DATE (Mo., Day. Yr.)
<br />January 22, 2016
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />onset to death
<br />16. WAS MEDICAI.
<br />OR CORONER
<br />❑ YES
<br />STA
<br />Nebraska
<br />21c. WAS AN AUTOPSY PERFOR
<br />❑YES $NO
<br />21d. WERE AUTOPSY FINOINGSA
<br />TO COMPLETE CAUSE OF DEATH?
<br />[3 YES 0 N
<br />STATE 21P LXGDE
<br />24b. TIME OF DEATH
<br />68801
<br />24a. On the basis of examination adlor investigation. 4r MY o*Utaa dba Oc weed
<br />at Ire lime, date and place and due to the cause(s) stated. (Signature and TRIO
<br />LSD TOSACCO:USE CONTP3BUTE TO THE DEATH? 264 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />Y D ENO ❑ PROBABLY UNKNOWN OYES Q NO
<br />27. NAME, T1TtE AND ADDRESS OF CERTIFIER (Type or Print)
<br />CL rtittatel t° 1 4,14fk- C> . S% c �fZi L-t set s ue-,vt tB 77
<br />15*.15EGFSTRXR`S
<br />SIGNATURE 25, DATE FLED BY REGISTRAR ( eo., Day Yr.)
<br />JAN 2 2 2016
<br />Mb. WAS CONSENT GRANTED?
<br />Not Applicable If 26a i• NO ❑ YES >
<br />I
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