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WHEN THIS COPY CARRIES THE
<br />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 SE VICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS it
<br />•
<br />DATE OF ISSUANCE
<br />SEP 15 2.016
<br />LINCOLN, NEBRASKA
<br />1.. DECEDENT'S -NAME (First,
<br />Mae
<br />Middle,
<br />H.
<br />Last,
<br />O 'Nele
<br />:Suffix)
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />4721 Stuhr Road
<br />9b.cOUNTY
<br />Hall
<br />lIa. MARITAL STATUS ATTtME OF DEATH ❑ Married ❑ Never Married
<br />0 M ted, tut separated 11Widowed 0 Divorced ❑Unknown
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />:.:. 11. FATHER'S•NAME (First,
<br />Albert
<br />Middle,
<br />T.
<br />Last, :Su:lllz)
<br />Hein'
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes.
<br />(Yes; no, or unto : :: No
<br />15. METHOD OF DISPOSITION
<br />pouriat ❑ Do ration
<br />❑ Cremation ❑ Entombment
<br />Q Removal 0 Other (Specify)
<br />16a. EMBAL R- SIGNATURE
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d: APT. NO
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />14a. INFORMANT -NAME
<br />James P. .0' Nele::. III
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 27, 2008-
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />October 27, 1914
<br />SOCIAL SECURITYNUMBER
<br />506 -28 -1759
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />St. Medical Center
<br />Si. PLACE OF DEATH
<br />IIDSFITAI
<br />❑ rnparient
<br />C$ER /Outpatient
<br />❑ :D04 ' .:
<br />QM: ❑ Nursing Home/LTC ❑ Hospice Facility
<br />❑ Decedent's Home
<br />❑ Other(Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />lob. NAME OF SPOUSE (First, Middle. Last, Suffix) 11 wile, give maiden name.
<br />Lloyd :.0''Nele
<br />12. MOTHER'S-NAME (First,
<br />Emilie
<br />Middle,
<br />Malden Surname)
<br />Falldorf
<br />68801
<br />9f: ZIP CODE
<br />16b. LICENSE N0.
<br />• 1143
<br />CITY / TOWN
<br />Grand: „Island
<br />99. INSIDE CITY LIMITS
<br />❑ YES Xj NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />180. DATE (Mo., Day, Yr. )
<br />January 2, 2009
<br />Nebraska
<br />STATE
<br />17b. Zip Code
<br />17a, FUNERAirHOME NAME AND MAIL NG ADDRESS (Street, city or Town, State)
<br />tivngston- Sondermann Funeral Home 601 N. Webb Rd. Grand Island, Nebraska 68803
<br />iii • -,r ;:1rJfvs ?4 °c'
<br />CAUSE OFD.DEATj1 (See:.instructions; and examp)es)
<br />18 PART I. Enter the chain of events-diseases, injuries, or complications-that directly caused the death: DO NOT.enter terminal events such as cardiac arrest,
<br />- reap ratpry erresL ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Eater dilly one cause one Iine,Add additional lines 11 necessary.
<br />IMMEDIATE CAUSE(Fi al
<br />disease or condhion resulting
<br />Indeastj
<br />•
<br />Sequentlapy list conditions, If
<br />any. teadln¢to4h #.Caueeltsted
<br />on knee.
<br />Enter the UN DERLYING CAUSE
<br />(disease or Injury that initiated
<br />theeventsresulstirtg:indeath)
<br />1Asy' II:
<br />•
<br />22a. DATEOF : INJURY (Mo., Day, Yr.)
<br />22d:INJURY:ATWORK?
<br />l YI• :::❑::NCI
<br />285. Et EGISTRAR'8 SIGNATURE
<br />P iP FEMALE:.::;
<br />$) :Not pregnantwithln past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ .t'(pt.pregnadt. but pregnant 43 days to 1 year before death
<br />?J thiatown it pregnant within the past year
<br />22L LOCATION CF INJURY- STREET S NUMBER. APT. NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />286.DAT£SIGNED (Mo.. Day, Yr.)
<br />STATE OF NEBRASKA
<br />201607224
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPO
<br />CERTIFICATE OF DEATH
<br />IMMEDIATE IMMEDIATE CAUSE:
<br />(a) senescence
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />5)
<br />DUE TO, OR AS CONSEQUENCE OF:
<br />(1)
<br />DUE T0, OR AS A CONSEQUENCE 0F:
<br />(dl
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />22b. TIME OF INJURY
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title) V
<br />p a. MANNER OFOEATH;:,.
<br />,QI Natural ❑ HdiiQide
<br />❑ Aceident❑ Pending Investigation
<br />❑Suicide ClCould not bedetermined
<br />m
<br />23c.TIME OF DEATH
<br />CRY ,,•
<br />� 9N¢
<br />Ba
<br />E aJ
<br />N I-•}
<br />832
<br />W =
<br />a 0 0 0
<br />OR V :.
<br />0 0
<br />DIDT08ACC0 CONTRIBUTETOTHEDEATH? Ftp. HAS ORGAN OF TISSUE D
<br />❑ YES ❑ NO ❑ PROBABLY Ci(UNKNOWN ❑ YES p NO
<br />•
<br />NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Aaron Kunz, Deputy Hall County Attorney, 231 S. Locust
<br />2(b. IFTRANSP0RTATION INJURY
<br />❑ Orfverooperator
<br />0 Passenger
<br />❑ Pedestrian
<br />.... ❑:Otber (Specify)
<br />22c. PLACE OF INJURY -At home, farm. street, factory, office building, construction site, etc. (Specify)
<br />STATE
<br />W. ()ATE SIGNED (Mo., Day,Yr.)
<br />pr4 '.11 2008
<br />c. PRONDUNCEDDEAD (Mo., Day, Yr.)
<br />December 27, 2008
<br />lee. On the basis of examin
<br />the time, date
<br />• ION C QNSIDERED?
<br />STANLE°t'S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />- HUMAN SERVICES
<br />APPROXIMATE INTERVAL::..
<br />1
<br />AOnset to death
<br />gradual
<br />onset to death
<br />onset to death
<br />I onset to dead)
<br />0. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />11] YES CI NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES 4a NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE T0
<br />COMPLETECAUSEOFDEATH?
<br />YES 111 NO
<br />r dBb.TIMEOFDEATH
<br />11
<br />ZIPCOD
<br />am
<br />325d. T)M E PRONOUNCED DEAD
<br />11 :23 a m
<br />nv stigation, In my opinion death occurred at
<br />`a D eputy ° Hal Tlt C o u nt
<br />. 9b. WAS CONSENT GRANTED?
<br />Not Applicable II 26a Is NO ❑ YES ❑ NO
<br />Street, Grand Island, NE 6880
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JAN 6 2009
<br />
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