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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 RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE JUN 0 2 2008 LINCOLN, NEBRASKA 1. DECEDENT'S -NAME (First, Middle, 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Council Grove, Kansas 7. SOCIAL SECURITY NUMBER 8b. FACILITY -NAME (If not institution, give street and number) 3166 North Monitor Road 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island, Nebraska 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 3166 North Monitor Road 10a. MARITAL STATUS AT TIME OF DEATH 9 Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Fred 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. (Yes, no, or unk.) No 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation fjCremation ❑ Entombment ❑ Removal ❑ Other (Specify) 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livin IMMEDIATE CAUSE (Final g. (a) diseaseor condition resulting DUE TO, OR AS A CONS UENCE OF: in death) Sequentially list conditions, P any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or Injury that initiated (c) the events resulting in death) lAsr 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.) 22d. INJURY AT WORK? ston - Sondermann F.H 601 North Webb Rd. 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. LI YES ❑ NO .3a. DATE OF DEATH (Mo., Day, Yr.) 7 C May 17, 2008 23b. DATE SIGNED (Mo., D y, Yr.) )(23c.TIME OF DEATH Day, 8:15 P m 23d.To the best of my knowledge, death occur ed at the time, date and place X an t - cause(s) stated. (Signature and Title ) • 01" Wi-e., ten- 1 /oe. v25. DID TOBACCO U' ONTRIBUTE TO THE DEATH? 28a. REGISTRAR'S SIGNATURE STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FMNANG ANDSUPPO T CERTIFICATE OF DEATH r 08-25346 Sallie Oleta 507 -36 -1992 (b) 16a EMBALMER-SIGNATURE Not Emb almed 16d. CEMETERY, CREMATORY OR OTHER LOCATION IMMEDIATE CAUSE: 9b. COUNTY Hall DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: (d) 22b. TIME OF INJURY m 22e. DESCRIBE HOW INJURY OCCURRED 201604434 Last, Baxter 5a. AGE -Last Birthday (Yrs.) 73 Last, Suffix) Sundeen 14a. INFORMANT -NAME Daryl Baxter 21a. MANNER OF DEATH X)iir Natural ❑ Homicide ❑ Accident() Pending Investigation ❑ Suicide ❑ Could not be determined CRY/TOWN .0 0 2 ❑ PROBABLY ❑ UNKNOWN ❑ YES K Suffix) 8a. PLACE OF DEATH HOSPITAL: 5b. UNDER 1 YEAR MOS. Sc, CITY OR TOWN Daryl Baxter HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? t `S TANLEY S. COOPER ASSISTANT STATE REGISTRAR HEALTH AND HUMAN SERVICES DAYS 9e. APT. NO 16b. LICENSE NO. 2. SEX Female Sc. UNDER 1 DAY HOURS ❑ Inpatient OTHER ❑ ER /Outpatient ❑ DQa MINS. 8d. COUNTY OF DEATH Hall Grand Island 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. 12. MOTHER'S -NAME (First, Elizabeth CITY / TOWN Grand Island 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 9f. ZIP CODE 68803 NE 24c. PRONOUNCED DEAD (Mo., Day, Yr.) ❑ Nursing Home /LTC ❑ Hospice Facility DO Decedent's Home ❑ Other (Specify) Middle, Westlawn Memorial Park Crematory Grand Island, Nebraska 18. PART I. Enter the ghain 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 if necessary 3. DATE OF DEATH (Mn., Day, Yr.) May 17, 2008 6. DATE OF BIRTH (Mo., Day, Yr.) July 24, 1934 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 9g. INSIDE CITY LIMITS ❑ YES I NO Maiden Surname) McElroy 14b. RELATIONSHIP TO DECEDENT Husband 16c. DATE (Mo., Day, Yr. ) May 19, 2008 24b.TIME OP DEATH STATE 17b. Zip Code APPROXIMATE INTERVAL onset to death IX I onset to death x onset to death onset to death X19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES X3 NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES tl NO STATE ZIP CODE 24d. TIME PRONOUNCED DEAD m 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 Title) x 26b. WAS CONSENT GRANTED? • Not Applicable if 26a is NO ❑ YES 1NO ❑ YES )8C NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY A 0 RNEY) (Type or Print) - 374t.1 VA 'JJv E V11- o . 'F y ► ' C , �y� Ts 69-rtn N E .. 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) MAY 21 2008