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1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Ira Lee Simons 2. SEX : ' Male . 3: DATEt9l' pfMH(MAdrDay,Yr.) August1 s2(110 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE -Last Birthday (Yrs.) 72 5bNDER 1 YEAR .0 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) July 8, 1938 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -42 -3844 8a. PLACE OF DEATH HOSPITAL: ❑ Inpatient OTHER: ❑ Nursing Home/LTC ❑ Hospice Facillty ❑ ERIOutpatient lil Decedent's Home ❑ DOA ❑ Other(Specify) 8b. FACILITY -NAME (If not Institution, give street and number) 806 E. 14th St. 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 806 E. 14th St. 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® Yea ❑ No 10a. MARITAL STATUS AT TIME OF DEATH lJ Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name. Lorraine Janice Eggers 11. FATHER'S -NAME (First Middle, Last, Suffix) LeRoy Simons 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) Rose , Kent 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, orunk.) 08/16/56 - 11/01/57 14a. INFORMANT -NAME Lorraine Janice Simons 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION El Burial Donation ❑ Cremation ❑Entombmem ❑Removal ❑OtherlSpecity) 169. EMBALMER - SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) August 20, 2010 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART 1. Enter the chin or evems - diseases, injuries, or complications- Mat directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL tat, aat, or ventricular fibrillation without showing Ma edolo ^. 0O NOT ABBREVIATE. Enter on!y one cause on a Ens. Add addditional lines n necessary. mu tA Yt 1 n I.-, � /\ on t t�geatf� 2 p Q "] e IMMEDIATE CAUSE: tt 1 M9 _ ,, rl „ 1 1,. VC. IMMEDIATE CAUSE (Final U �J "`- 1. / �'/ �! I \ � t G V / disease or condition resulting a) AU X In death) r C/r • ®T Lp`d DUE TO, OR AS A CONSEQUENCE OF: t onset to d Sequentially list conditions, If b) •....----, any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) �"- (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) - 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART 1. , C � � ( � V r � 19. WAS MEDICAL EXAMINER O R CORONER CONTACTED? ❑ YES g<40 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death 13 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 ['Unknown 21a. MANNER OF DEATH ❑ Natural ❑ Homicide - ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined gpri, 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY � PERFORMED? ❑ YES iUcTNO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEAT ❑ YES ❑ NO /1/ 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 W K? ❑ YES NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET a NUMBER, APT. NO. CrrYITOWN STATE ZIP CODE W rr. F oQO y U a p O W 238. DATE OF DEATH ( D , Yr.) A 1 (. ' ' � r/ ( LTV ` V T g W a U Z ms } O = , Er n z 0 w Z . Z O 7 8 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH m 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD m 23b. D TE SIGNED ( o., Day, Yr.) � �° � 23c. TIME OF DEATH 5` � 8 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) 23d. To the best of my knowledge, death occurred at the time, da and place and due to the cause(s) s (Sig re and Title) �J 26. DI TOBACCO USE CONTRIBUTE TO THE DEATH V D YES ❑ NO ❑ PROBABLY ❑ U OWN 26a. HAS ORGAN OR TISSUE DD NATION BEEN CONSIDERED? ❑ YES X1 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES I/dN0 7. NAME, TITLE AND ADDRESS OF CERTIFIE YSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Sitki Copur M.D., 116 W. Faidley Ave. Grand Island, Nebraska 68803 28a. REGISTRAR'S SIGNATURE �� d, ►r� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) AUG 25 2010 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ,AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA ^ DEPARTMENT OF 1- IEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR ix'ITAL \ RECORDS :.. `, ) DATE OF ISSUANCE AUG 2 6 LINCOLN, NE STATE OF NEBRASKA STAN S LEY , cQ.QPER 2010 AS,'SISTAN7� 7 WE=E,EC7ISTRAR DEPA'Q fMENT OF` I4EALTH AND NEBRASKA HLJMA' ' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVI?ES) ' • ` C ERTIFICAT E OF DEATH I ( . r • '" • 201703604