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STATE OF NEBRASKA 2016 O 3 2 9 g
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND l/LEAN SERVICES,IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL REC`o DS.
<br /> DATE OF ISSUANCE
<br /> •
<br /> STANLE •'S. COOPER
<br /> 07/05/2012 ASS�S-TANT STATE REGISTRAR'.,', i
<br /> DEPARTMENT-OF HAAt,TN AND
<br /> LINCOLN, NEBRASKA HUMAN SERVICES
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<br /> STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICES '12 (�,/�, A
<br /> CERTIFICATE OF DEATH vF�r-r
<br /> 1.DECEWENTS.NIIME (First,:. Middb, :Last, Suffix) 2.SEX 3.DATE OF DEATH(Me,.DW.Yr.)
<br /> Merton LeRoy Norton , Male June 28,2012
<br /> 4 CITY AND STATE OR TERRITORY,.OR FOREIGN COUNTRY OF BIRTH Ile AGE-Last Sb.UNDER 1 YEAR Sc.UNDER 1 DAY i.DATE OF BIRTH IM0.,Day,Yr.)
<br /> (Yrs.) MOS. DAYS HOURS buNS.
<br /> Malvern,Iowa 84 June 13,1928
<br /> 7.SOCIAL SECURITY NUMBER Se.PLACE OF DEATH
<br /> 507-28.452 1'IMEM.:IE IppWrnt 4I1EB:0 Nursing HulWLTC ❑Hoar •FacUEy
<br /> 1- s.FACNJTY.N7Ui1E(If not Institution,give sheet and numbrr) ❑RWOr lPMWt D Dacrdwr.Rarer
<br /> V
<br /> Veterans Affairs Medical ❑DOA ❑cal Center oaar(ap.elyl
<br /> e
<br /> Sc.CITY OR TOWN OF DEATH(Include)1p Coda) ea.COUNTY OF DEATH
<br /> Grand Island 68803 Hall
<br /> Z H. Si.RESIDENCE..STATE Ob..COUNTY :Sc.CITY OR TOWN
<br /> H.
<br /> Nebraska Hall Grand Island
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<br /> 9d.STREET AND NUMBER 0..APT.NO. Sf.ZIP CODE 9g.INSIDE CITY LIMITS
<br /> 2220 S.Blaine 68801 ®Yes ❑No
<br /> 1.e 10a.MARITAL STATUS AT TIME OF DEATH 12f Ranted ❑Never Manle'II 100.NAME OF SPOUSE(First,Middle, Last. Suffix)I MN,dive maiden name.
<br /> ❑Mantak but separated❑.Widowed ❑Divorced :❑Un OViF I Betty: Bates
<br /> 1I..FATHER'S•NAME (First, mass. Last, Suabt) 12 MOTNER'S-NAME(First. RIddb,. Maiden Somer.)
<br /> Dennis Paul Norton Mildred Scott
<br /> A 13.EVER IN U.S.ARMED FORCES?Ohre dabs of sorties N Yes. 14..INFORMAHT4IAME 14b'REUITNDNSHIPTO DECEDENT
<br /> h
<br /> nes,No,orurw.)Yes 07/18/1951-03/20/1963 Betty Norton Spouse
<br /> 14 MET/10130F DISPOSITION 1$..EMBALMER-SIGNATURE 100.LICENSE NO. lec DATE(Mo.,Day.Yr.)
<br /> ❑WOO ❑°admen Not Embalmed June 29,2012
<br /> IECNnatlea ❑Edreaboret
<br /> , s e°..t 10d.CEMETERY,CREMATORY OR OTHER LOCATION : CITYITOWN STATE
<br /> Central Nebraska Cremation Services Gibbon Nebraska
<br /> 17a.FUNERAL HOME NAME AND MAILWG.ADDRESS(SOW.City or Town,Stns) 170.:32pCode
<br /> All Faiths Funeral Home,2929 S.Locust Street,Grand Island,Nebraska 68801
<br /> CAUSE OF DEATH(See Instructions and examples)
<br /> it,PART I.Martha shimmowsw.aimses.Inhales,or covalleadreie.Owl ellently awed Ihe*rah DO NOT valor lemansl nods soca as raiding area, 'APPROXIMATEIITERVAL
<br /> ,woleawy meet or v**NaarIDO sum wNlout awwlne as ellolegy.DO NOT ABBREVIATE.Miler only ea.raw on aar Ada eddaeat sees It merman/. .
<br /> IMMEDIATE CAUSE: 1 onset to death :.
<br /> IMMEDIATE CAUSE(Final (�('�`j /1� /� ` s . ` ;
<br /> Mdl )Cendlnen reaWting a) V.CkMI'1 ]'1\91 f N ©c . W.`\ ,
<br /> DUE TO,OR AS A CONSEQUENCE OF: i onset to death
<br /> Ssqusntlaiy Ilet corrdliom.N b) "�,`..� �..�`1 G .
<br /> Try,wrong to are ease listed f� ``�.�T d'l
<br /> ondnea. 1DUETO.ORASACONSEQUENCEOF:. : 'onset totoath
<br /> I
<br /> Enter the UNDERLYING CAUSE c) (� 1�+ 1 ,„,,,,,\Q t l '„0.S(' : '..
<br /> (disease or lohlrythat Inlseted
<br /> a a*vows...Nine in duo)...DUE TO,OR AS A CONSEQUENCE OF: ,onset to death
<br /> LAST i
<br /> I
<br /> d) I
<br /> II.PART IL OTHER S otassc NT CONDI110•$.Caldtlans fie tribuUng to the death but not resulting In the underlying cause given In PART L 10.WASMEDIICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> tg �`®!®e. L 4ei. ❑YES )(NO._
<br /> 20.IF FEMALE: : \ \ 21a.MANNER OF DEATH 21b.IF TRANSPORTATION INJURY 210.WAS ANA PERFORMED?
<br /> U.t ❑Not pregnant within puny.. dal ❑Honiade ❑Druver/Operator ❑Y!8
<br /> M ❑Pregnant at time or dam ❑Accident ❑Pending MwatIgaaon :❑Pase ger 21d.WERE AUTOPSY FINDINGS AVAILABLE
<br /> ?. ❑Net pregnat,but pregnant within 42 days of death ❑Suicide ❑Could not be determined :.❑Pedestrian To COMPLETE CAUSE OE DEATH?
<br /> . ❑Not pregnant,but pregnant 43 days to 1 year before death ❑osier(Speedy) ❑YES 114
<br /> 1 ❑Unknown If pregnant within the poet year
<br /> C.
<br /> Q 22a.DATE OF INJURY(Mo.,Day,Yr.) 2212.TIME OF INJURY 220.PLACE OF I JURY,At home,lank abort,factory,oar*building,construction rite,ete.(Spady)
<br /> 1y07 m
<br /> ::.Q 22d.INJURY AT WORIC? 22e.DESCRIBE HOW INJURY OCCURRED
<br /> I- D YES 151
<br /> 221.LOCATION OF INJURY.STREET&NUMBER,APT.NO. :.: CITY/TOM/11 STATE : ZIP COOS
<br /> 23a.DATE OF DEATH(Mo.,Day,Yr.) 219.DATE SIGNED(No,Day,Yr.) 24b.TIME OF DEATH
<br /> $C JkkJttlt c`�$ ,ac, c� .lya'MMMsa m
<br /> 1 2312.DATE SIGNED(Mo..Day,Yr.) 23c.TIME OF DEA S 210.PRONOUNCED DEAD(14o.,Dry,Ye, 24d.TIME PRONOUNCED DEAD
<br /> sug A Re a9 acs lb' Am; 3llrA<o m
<br /> :. 23d.To the best of my:.■ '°•', death ocetned at the time,dab and place k 24e.On Ms bats of exaNnaaon a dfor Imandgrtlon,In ray opkton death Occurred
<br /> F t mi.) E at the lIen.,del.end piano and donto the c.un.(a)staled.(Signature and TRIO
<br /> ,
<br /> - ,41!"...„..0-1:0° ®(4-9 ~ t
<br /> 30.DID ,.0 «. TO THE DEATH? 26a.HAS ORGAN OR TISSUE DONATION SEEN CONSIDERED? 210.WAS CONSENT GRANTED?
<br /> p , ❑YES 'RHO ❑PROBABLY: ❑UNKNOWN ❑YES I(NO Not ApplleabN M 2a le NO ❑YES l'..l5k0
<br /> 27.NAME,TITLE AND ADDRESS OF•"^11FIER(PHYSICIAN,PHYSICIAN ASSISTANT,CORONER'S PHYSICIAN OR COUNTY A HEY)(Type or
<br /> of cT So cN'41e.NIVI tt MO VAii e-0/9o1 N ro aetwel( 6caa I tine) Qncc L '6�$a3
<br /> 20a.R s SIGNATURE 210.DATE FILED BY REGISTRAR(M0.Day,Yr.)
<br /> P
<br /> 444E111.
<br /> JUL $ 2012
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