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<br /> end# : „Itei 4 ti1t4!ieaiil.:"jt i#ii)i.`- PL t 5 titiiit'd+I :M iii .� }0.!i`5I, €3 j.IeskRR'u, ;,4,- tt Y'S%# i I; tt III .s t9 i
<br /> ti ,) ,c-Ve s ;V C STATE OF NEBRASKA , ,y,, , 4V� y N\�.
<br /> r�,i, � i, i, ,�;'t riii
<br /> WHEN ! THIS ! COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT '*,,,t
<br /> CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD o4KE S T9 TF OIiIII
<br /> ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL i Q .n■Ito,
<br /> p
<br /> RECORDS OFFICE, WHICH IS THE LEGAL.DEPOSITORY FOR VITAL RECORDS A ft., ( ..' w 1
<br /> DATE OFISSUAN CE STANLEY S. DOPER \��0 ~%�/ `�1'^ e,
<br /> i� �'+i .+� ASSISTANT STATE REGISTRAR s �,a '"'„,..,4,-/
<br /> 05/18/2016 2 01.6 0 6 9 31 DEPARTMENT HEALTH AND �Igtlt V�,o, �t
<br /> HUMAN SERVICES ���RC�.i.,2-,,,
<br /> LINCOLN,NEBRASKA
<br /> STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICES ',5 w.d�,,
<br /> .ice _ .A t} * r
<br /> t.DECEDENT'$-NAME (Float, Wadi., teat. $wRi;t) 2.SEX 3,DATE OP'OEATM;Ma..Day,Yr.)
<br /> Lek0 francs Allen Jr Mali; Ma 1,2016
<br /> 4.CITY AND STATE OR TERRITORY.OR FOREIGN COUNTRY OF BIRTH Se.AGE-last Birthday Sb.UNDER 1 YEAR Sc.UNDER 1 DAY 6.DATE OF BIRTH(MO.,Day,Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br /> Porthancl.Oregon 71 March 18,1945
<br /> T.SOCIAL SECURITY NUMBER •0e*.PLACE OF DEATH
<br /> 508=60-0765 t!1L st.,0 kiaati.at QTH t 0 Nrnehr0 Ha+neR.TC []Hospice fecitity
<br /> Sit.FACILITY-NAME(0 not Institution,give street and eventlerl 0 EF,Oetpatient 50 Decadent's Hama
<br /> 4301'Clausen Rd 0 DcA [1DtlarBpeclty) ,,,
<br /> ft..CrT'Y oe Ti,)WN OF DEATH(Gtcctuda Z(p Code) Bd.COUNTY OF DEATH ::
<br /> Grand Island 68803 Hall
<br /> , ,a.RESIDENCE-STATE Eb.COUNTY Sc.err(OR TOWN
<br /> Nebraska , Hall Grand Island .
<br /> i Sd_STREET ANC NUMBER le.AT NO M.ZIP CODE 6g.INSIDE CITY LIMITS
<br /> 4301•Claussef Rd � 68803 g]Yea ©Na
<br /> 1Oa.MARITAL STATUS AT TIME OF DEATH al Married 0 Never Married 1 Ob.NAME OF SPOUSE(First,Middle, Last St fist it wit&givo tnaiden name. ..
<br /> • ❑Mamiad,but separated 0 widowed u Dlvtlread 0 Unknown Sherityn Jean Lute
<br /> :: L . ' 12,MOTMER'S•HAME Feet. Middle, Maiden Surname)
<br /> 11.F'i);TNER'$•NAME (First, Middle, tact. $uRnd 1
<br /> ' LeRd •;`rands Alien Sr Frances Urioste
<br /> 3 13 .EVER IN U.B.ARMED FORCES?Give dates of service if Y . 14a.tNFORMANTAIAME 141.REt.ATEdNSM)P TO DECEDENT
<br /> ' (Yea,No or Unk.t Yes 11/24/1965.11;22/1967
<br /> Sheriiyn Jean Allen Wile --
<br /> is,NIETHODOF DISPOSITION 10A.EMEALMER- NATU1 . lab,LICENSE NO. 14e,DATE 4W-Day.Yr,)
<br /> rE„ri.t Doanatssr r "" $k3 a itl,L,Sefl Ma 6 2016
<br /> QCrarnAaen •rjtroamamant STATE
<br /> h..- ... �de*hadapa<l y) 16d.CEMETERY,CREMATORY OR, HER LOCATION WTI-TOWN
<br /> Grand island City Cemetery Grand(stand Nebraska
<br /> lie..FUNERAL:HOME NAME AND MAILING ADDRESS IStreet,City or Town.State) 17b.Zip Code
<br /> Al Faithn Funeral Home,2929 S.Locust Street,Grand island,Nebraska 68801
<br /> ' CAUSE OF DEATH See instructions and exam.lee _
<br /> W 10.PAitI I Ent*tIre•
<br /> ;,MateE ECNOS-aseasaa,mewls.or ceopacatinnt-trot moue...auto owe as th,00001 aotm tertmoat araars arws or carawu erraai, APPROXIMATE INTERVAL.
<br /> nweiratery 0100.Or vtna;aal01 F.atrnai.on antlwut anvwnra Ow otror00y,ON NOT AOttEWrTE.Entor onip ono eause an a Dm,.8.04 addieonn Noes a e cataary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> ji-1/0,,,•::.j:. .f
<br /> IMMEDIATE CAUSE:1Finai ,� o' +Y Ira- _ j J: "r_ t .:, . S'w' ! 4
<br /> 404:14%01 orcotldioatt taswling a)" t..h �. ('°„ Y "A1 `irS e' ° I q,.,...i--""" a, :_
<br /> iti death( l_'
<br /> :. DUE 70,OR AS A CONShn2U.N E Of onset to daalh
<br /> Soquentia)iy het cotrditiona,II y4w ,.^ .. r �+ a,,, w
<br /> ally,ieadwtg to tae c000se fisted/' I t>`.. /' ``--'r�'�0 t'f1 U s-v a4 .../ `f" " G�.> ..w Y}'"I e 7-C�
<br /> on 40.a DUE TO OR AS A CONSE s '.. -a.,:_. ( _.. -*».w^'---t,' '? onset to death
<br /> r p21 atpi S
<br /> Ent***UROEktLYING CAUSE f) 1`S A F'I`}tT Y4 a cA Y4. r�/3 1 d r 4 a ``2 an l ✓r flee,,y"r Tft es e*/.4;t rM t
<br /> (4( i ea Or etltl)`that ideas ea DUE TO,OR AS A CONSEQUENCE OF: I onset is deaM
<br /> 11x0 avant,,tailing to deeth)LAST
<br /> I is BIGNIFICANT CONOITIONS•COOdidana contributing to the death but nut fustettled 10.:0M undeoIyIre aloes given En PART I, 10.WAS MEDICAL EXAMINER
<br /> t6,PART g.fiyT, OR CORONER CONTACTED?
<br /> .` P. :, L,,JV V a,t 14-77,11,// r 1,,-i-<../,1-
<br /> ri 1 ✓e l tFe t� .t ❑YES NO
<br /> 20.IF F f 2Ta.MANNER OF/DEATH 211.IF TRANSPORTATION INJURY 21c.WAS AN AUTOPSY PERFORMED?
<br /> [Nat pra5RPntw(tfiil poet year �,Naturai [,}1.0..1 Olds Driver/Operator ❑YES tIO .., :.
<br /> J [A?o$nanl at time.of death [ Accident Y,!Kting tmreelgattan [�Paaatn$ar 21 d.WERE AUTOPSY FINDINGS AVAILAMLE
<br /> 2 .01100 9105nat1E.but pregnant within 42 days of death 0 Suicide* 0 Cotdd nrn he daferrrened 0 Pedestrian TO COMPLETE CAUSE OF DEATH?
<br /> SS' tDNUt pregnant,0C*pregnant.43 day,tat year hefora dealt 0 Other(Specify) D YES ONO
<br /> i : [Unknown If pregnant within the past year :.
<br /> 1 . 22a:<DATE OF INJURY(Mo.,Day,Yr.) 22b.TIME.OF INJURY 2201 PLACE OF INJURY-Al 1tome,MOM,&SWL 140101?office tut)ding.Con0truttO1 Oita,elm.ISttaclty}
<br /> S >:., m .,
<br /> 22d.INJURY AT WORK? 220.DESCRIBE HOW INJURY OCCURRED
<br /> D
<br /> D YES 0 N
<br /> 22?:LOCATION:OP INJURY STREET&NUMBER,APT.NO CITWTOWt4 STATE ZIP CODE
<br /> 23.DATE OF DEATH(Mo.,Day.Yr.) °s4e DATE SIGNED 1100.,Day,Yr.) 241.TIME OF DEATH
<br /> y�
<br /> tt.' (11ty! i "t} Ie' A'Wx -- m
<br /> .2 286.DATE SIGNED(Mo.,t7ey,Yr.t' 23c.T9ME OF DEATH r 24a.PRONOUNCED DEA67!Md,.Day,Yr.) 24d TIME PRONOUNCED DEAD
<br /> 4k,F5>. r rf a
<br /> E?. ..t` is i t, , 2 )3 '' rn . MrrwrMww+.wrw: -. m. v=
<br /> o w&: 24a.Qr tl.twaie at asamination and/or invealgattolt in my atrenlun de001 dt.OQ
<br /> LT: 23q.end d "1 of = teNN4)eat)e,.(Sign atcrered al the time,date 4nd pl;tce t1-:,u, >al t e Erne,Oat and pace and duo 10 the tauae{,I eta1ad)SISnettaa 0103 TTI}E)
<br /> �+'�: one due to the Ceasa{a)elated,(Signature and Tide) A. !�:�
<br /> 411111***10111111111111MAIMIN4011111111* 111110011101M11110110.
<br /> 12.DID 1085 Tee USE CONTRIBUTE TO THE DEATH? 240.HAS ORGA.NOR TISSU�E(DONATION BEEN CONSIDERED? 2011 WAS CONSENT GRANTED? `^D
<br /> 0 YES [lip 0 PROBABLY JNKNOWN t ID YES 4 NO Not Applie a K 260 is NO 0 YEs ..NO,"": -
<br /> "2T%NAME.T€TL:E AND ADDRESS OF CERTIFIER(type Of Prhd( , r... 1
<br /> }, ,}:I.L,,t 7i;p{Kt1.s /$r 7) 5r� tvr.rO . LI-en o,r (Yuo, a 1o" 'ti'C h1'p
<br /> 2 REfirt?TRARS SIGNATURE d J j 206,DATE FILED EY REGISTRAR)MO Gay,Yr I
<br /> � MAY 16 201
<br />
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