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1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Charles Robert Hill 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) November 28, 2006 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Council Bluff Iowa 5a. AGE -Last Birthday (Yrs.) 83 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) September 4, 1923 MOS. DAYS HOURS .MINS. 7. SOCIAL SECURITY NUMBER 508-18-9386, 8a. PLACE OF DEATH HOSPITAL: ❑ Inpatient OTHER ail Nursing Home /LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not institution, give street and number) Veterans Affairs M 'dical Center 2201 N. Broadwell ❑ ER /Outpatient ❑ Decedent's Home ❑ _ ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand. Island 8d, COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island s 9d. STREETANDNUMBER I 2304 North S camore 9e. APT. NO El. ZIP CODE 68801 9g. INSIDE CITY LIMITS 12 YES ❑ NO x `; lEa. MARITAL STATUS AT TIME OF DEATH ($Married ❑ Never Married ❑Married,butseparated ❑Widowed ❑Divorced ❑Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name. Betty Miller ' tt 11. FATHER'S -NAME (First, Middle, Last, Suffix) William Robert Hill. 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Jessie Prater i' 13. EVER IN U.S. ARMED FORCES? Give dates of service ii yes. Ari - n y3 /2743- 12/27/45 14a. INFORMANT -NAME Betty Hill 14b. RELATIONSHIP TO DECEDENT wife '�i 15. METHOD OF DISPOSITION ❑Burial r�j Donation ❑ Cremation ❑ Entombment . _�t ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Not Embalmed 1 ( 16b. LICENSE NO. 16c. DATE (Ms., Day, Yr.') Nov. 2 8, 2006 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE Central Nebraska Cremation Service Grand Island, NE 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stale) 17b. Zip Code :11 Faiths Funeral Home 2929 S. Locust St. Grand Island NE 68:1 f v,?'r F ` ! g. `$' Y .3 �q i -4 .' "� y tl It u f �✓' I i.. ,, l h i i, n r " ,t 5.J L.ij 6 d, 5 16. PART I. Enter the chain of events -- diseases, In)urles, or complications- -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. I IMMEDIATE CAUSE: 1 onset to death (a) Con Heart Failure 1 IMMEDIATE CAUSE (Final C7 I disease orconditionresuiling DUE TO, OR ASACONSEQUENCEOF: I 'onset to death in death) Sequentlallylislcondttions,lf (h) Renal Failure any, leading inthecauselisted DUE TO, OR ASACONSEOUENCEOF: I onset to death A onlinea. EntertheUNDERLYINGCAUSE I (disease or injurythatInitiated )c) 1 I the eventsresultingin death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LASE (d) 18. PART ti. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given In PART I. �x�`. - 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑VES $I NO t 2o. IF FEMALE: o ❑Not pregnant within past year ' �J,y y ;�. ❑Pregnant et time of death " `' ❑ Not pregnant, but pregnant within 42 days of death � ," ❑ Not pregnant, but pregnanl43 days to 1 year before death ❑ Unknown if pregnant within the past year 21 a. MANNER OF DEATH Natural ❑ Homicide ❑Accident❑ Pending Investigation ❑Suicide ❑Could not be determined 21 b. IFTRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑Other (Specify) 21c, WAS AN AUTOPSY PERFORMED? ❑ YES X ENO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSEOF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) � 22b. TIME OF INJURY. m 22c. PLACE OF INJURY -At home, farm, street, factory, office bullding, construction site, etc. (Specify) _ q 22d.INJURYAT WORK? ❑ VES ❑ NO 22e. DESCRIBE NOW INJURY OCCURRED 221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CIIY/rOWN S1ATE ZIP CODE �'. E a Z o O W 23a. DATE OF DEATH (Me., Day, Yr.) Z } 24a. DATE SIGNED (Mo., Day, Yr.) November 28 , 2006 24b.TIME OF DEATH m 23b. DATE SIGNED (Mo., Day, Yr.) N ovember 28 2006 23c. TIME OF DEATH m i 24c. PRONOUNCED DEAD (Mc., Day, Yr.) • _ m E A a Z 24d. TIME PRONOUNCED DEAD 23d. To th- .est of my owledge, de: occur ed at the time, date and place 8 w 24e. On the basis of examination and /or Investigation, In my opinion death occurred at an d - to e c se(s) state. . ignatu e and Title ) ♦ 2 z p the time, date and place and due to the causes) stated. (Signature and Title } ` � ~¢ U Art /L/ V O 1�Ph- _ 25. DIDTOBACCOUSECONTRIBUTETOTHEDEA ? A ❑YES ❑ NO ❑PROBABLY W UNKNOWN 26a. HASORGANORTISSUEDONATIONBEENCONSIDERED? ❑YES NO 26b.WASCONSENTGRANTED? Not Applicable If 26a is NO ❑YES ❑ NO Z ¢ 27. NAME, TITLE AND ADDRESS OF CERTIFIER ( PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) ' Gar L. Vandewege. MD Va Medical Center 220 N. Broadwel . Grand Island NE 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) SEC 4 2 006 STATE OF NEBRASKA 201606534 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 ORIGINALREQL Ra FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION _IICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE DEC 0 5 2006 LINCOLN, NEBRASKA TANL£Y $.'FQO R ASSISTANT STATE$EG TRAR HEALTH-SIND HUMAN.SER1ES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE Fk$UPPO CERTIFICATE OF DEATH . 33001