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1. DECEDENT'S -NAME (First, Middle, Last, Suffix) . Eugene Edward Heying 2 SEX -: Male 3 DATEOPOEATH (MO .; Day, Yr.) March 6, 2005 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Petersburg, Nebraska 5a. AGE -Last Birthday (Yrs.) 70 5b. UNDER MOS. 1 YEAR DAYS ,5c. UNDER HOURS 1 DAY.. MINS. 6. DATE OF BIRTH (Mo., Day, Yr.) October 24, 1934 7, SOCIAL SECURITY NUMBER 507 - 36-1310 8a. PLACE OF DEATH HOSPITAL: 21 Inpatient OTHE Nursing Home/ITC ❑ Hospice Facility ❑ ER /Outpatient 0 Decedent's Home ❑ LOS ❑ Other (Specify) 8b. FACILITY -NAME (If not institution, give street and number) s St. Francis Medical Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 n 8d. COUNTY OF DEATH Hall ,7 a; 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2411 South Blaine 9e. APT. NO 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS X] YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH Married 0 Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 505. NAME OF SPOUSE (First, Middle, Last, Suffix) It wife give maiden name. Carol Heying ° - 11. FATHER'S -NAME (First, Middle, Last, Suffix) Jim Heying 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Monica Shad 13. EVER IN U.S. ARMED FORCES? Give dates of service tf yes. (Yes, no, orunk.) /23/1952 5/22/1955 14a. INFORMANT-NAME - Carol Heying 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ['Burial ❑ Donation 16a. EMBALMER- SIGNAT,,URRE� . ��' 16b. LICENSE NO. 44 /,:? ,5-. 16c. DATE (Mo., Day, Yr. ) March 10, 2005 Cl Cremation ❑ Entombment ❑Removal ❑ Other (Specify) 16d. CEMETER ✓CREMATORY OR OTHER LOCATION CITY /TOWN STATE Westlawn Memorial Park Cemetery, Grand Island, Nebraska 17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, State) Apfel Home, 1123 West Second, Grand Island, NE 17b. Zip Code 68801 INTERVAL to death -- �.. 414 �. p Funeral t� ! m�W"' ��" ?` 18. PART I. Enter he chain of events -- diseases, in;uries, or complicat'cre -that di; ea: y caused the death. DO NOT enter tcralia a1 events such es cardiac arrest, APPROXIMATE respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: onset IMMEDIATE CAUSE (Final (a) 6 -- b -0 C�l.�� C�,t) „I.L�C/ (, r 1 (-'- (..,c( P Ii l.. 4- disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF: onset to death In death) t' Sequentially llst conditions, It (b) `• '" any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death on line a. Enterthe UNDERLYING CAUSE (disease or injury that Initiated ( the events resulting lndeath) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST (d 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART!. � e 1".'a s et t e - L it) (a nee }..r ( ll//11.�� l� r t C/ 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑YES 0.,140 x i 20. IF FEMALE: ' ' ❑ Not pregnant within past year a y _ ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ar ❑ Not pregnant, but pregnant 43 days to 1 year before death 'srt ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH Natural 0 Homicide ❑ Accident0 Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IFTRANSPORTATION INJURY ❑Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ANC. 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ,f1 NO a, 22a. DATE OF INJURY (Mo., Day, Yr.) 22b, TIME OF INJURY m 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 221. LOCATION OF INJURY - STREET & NUMBER, APT. N0. CRY/TOWN STATE ZIP CODE � a yg I I, j s e r rno S r°-z vY a 23a. DATE OF DEATH (Mo., Day, Yr.) ¢ 24a. DATE SIGNED (Mo., Day, Yr.) March 6, 2005 ; -Z 24b.TIME OF DEATH m 23b. DATE SIGNED (Mo., Da , Yr.) - ? \ ICS Nrx 23c.TIME OF DEATH & > 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 2:40 a.m.m o¢ao 24d. TIME PRONOUNCED DEAD m 23d. To the best of my knowledge, death occur ed at the time, date and place u w z 24e. On the basis of examination and /or Investigation, in my opinion death occurred at an� due to the cause(s) stated. (Signet e and Title) • . wo o i2 the time, sate and place and due to the cause(s) stated. (Signature and Title ) • y/ (� 1 � l l 7 1I ,1/ l� � v/, I 0 o 25.010 TOBACCO USE CONTRIBUTE TOTHE OEATH? ❑ YES ❑ NO A PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES p NO 265. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER ( PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Anita Deshpande M.D. 2116 W. Faid ey Ave., Grand Island, NE. 68803 28a. REGISTRAR'S SIGNATURE 25b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) MAR 14 2005 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 JJNV FILE WITH ,\ THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTLCS SECTJON, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE MAR 2005 LINCOLN, 201'701.636 IA TAIVLEY S. A� _ N, NEBRASKA HEALTH- AIWD H1.1460I.` PVICE_ s STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINAI ;)r dPPOT - n CERTIFICATE OF DEATH