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<br />IEBRASKA >•
<br />WHEN THIS COPY CARRIES THE 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 SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />• DATE OF ISSUANCE
<br />05/10/2016 201707399
<br />NEBRASKA
<br />3
<br />I, DECEDENTE.NAM
<br />STATE OF NEB
<br />I 401,,, t.ast, SuflI* )
<br />Dan Valdaan Lacey
<br />4 CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hf11,:'Nebraska
<br />7;Sociati,•5severtv NURSE
<br />505424023
<br />FACILFTY44AME (If not institubOrt, give street and number)
<br />Veterans Affairs Medical Cente
<br />avinirres.NAME (Find, Middle, Last, S ix)
<br />Gu Lace
<br />ta everitim u,s ARMED
<br />es, No, or Unk.1 Yes
<br />2 Ghee deem o service 4 Yes.
<br />7 1 -07 1 59
<br />COUNTY
<br />16e EMBALMER-SIGNATURE
<br />Not Embalmed
<br />Patricia
<br />14a. INFORMANT-NAME
<br />Patrca Lace
<br />4344 APT.
<br />* 4, COUN
<br />Hat
<br />/Fiddle,
<br />4.
<br />SO, CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />94, RESIDENCE.STATE
<br />Nebraska
<br />aa,sTREST 'MO NUMOER
<br />4. 7: 2011 :Riv06ide Drive
<br />MARITAL STATUS AT TIME OF DEATH bij Madded 0 Never Mactiod
<br />"tarried, but separated 0 Widowed 0 Divorced 0 Unknown
<br />IL METHOD OE DISPOS ION
<br />. .
<br />:004 00.41130/1
<br />CIIRPOir0I1 OFADooDirtuott
<br />Ofismoviii 00,141,(Sporify)
<br />184, CEMETERY, CREMATORY OR Ottlek Loostioa
<br />Central Nebraska Cremation Services
<br />17. FUNERAL, HOME NAME AND MAILING ADDRESS (Street, City or Tow% Stet*
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />Mat Ittiodneent
<br />a)
<br />CAUSE OF DEATH See instructions and ex
<br />s, c DUD dose* tattascl K. 00 1407.10., 041 svonts ouch es candise amst,
<br />aDology. DO DOT ADDREDATE. EOMST only or* C.D. an a Rino. ADD sektniaroD linos if nscossary.
<br />L •
<br />A OX *NTERV
<br />1 , one* to defith„
<br />le PART I. Dotsw
<br />respiotany amst,
<br />••• btxtv MBE (Final
<br />ODOIDale contDDOO roosufting
<br />• • inderith)
<br />IMMEDIATE CAij
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list comlitIons. R
<br />aneMIIIEt the cause listed
<br />0*4 ........
<br />saaii CAUSE 41
<br />idnettese or injury that initiated
<br />the events remitting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />it, watt SiG
<br />d)
<br />year
<br />of dagth
<br />444tatlid, but pregnent within 42 days ot death
<br />,...,
<br />uNot pregnant, but pregnant 43 days to 1 year before death
<br />°Unknown if prOpant within the petit year
<br />.22IC.DATE.OF 142.1URY (Mo.., Day, Yr.I
<br />27, NA E, TITLE AND AD
<br />28a. REGISTRARS SIGNATURE
<br />DUE TO, OR *5 4* CONSEQUENCE
<br />- DEPARTMENT OF H
<br />40 0
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo.,D4y,W,1
<br />April 19, 2016
<br />URY
<br />m
<br />Mt. AGE-Last Birthday Sis. UNDER 1 YEAR
<br />77
<br />A TH AND HUMAN SERVICES
<br />MOS.
<br />H
<br />Ita, PLACE OF DEATH
<br />tioluTALIE
<br />0 ER/Outptitient
<br />0 DOA
<br />toc. C OR TOWN
<br />Grar*d lsland
<br />*TS
<br />Maulucci
<br />12, M0'TNER144AME (Fast,
<br />• Coral SChEDIO1
<br />• • • • • • . 184.
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />Gibbon
<br />UNDER 1 DAY
<br />MINS,
<br />M. ZIP CODE
<br />68801
<br />tab. NAME OF SPOUSE (First, Lem, Suffix) it wife, give maiden name.
<br />21a. MANNER Of DEATH 24b, IF TRANSPORTATION INJURY
<br />rimmrei pwapeng, 0 DrivenOptireter
<br />0 i d i ff 0 Fe n d 4 W 6444,1 KO tk* P "s"D 6 '
<br />0 Suicide 0 Could not kw deterittinand 0 Pedestrian
<br />0 Other (Spey)
<br />6 22594
<br />, DATE OF BUR a., DaY.'7.(
<br />Aug 3, 19
<br />taillgs; 0 Nursing Homo/LTC 0 HoflpiDO FDDDity
<br />0 Dem/ends Home
<br />o OthertSpncify)
<br />cavrrowN
<br />Les
<br />Maiden Surname)
<br />It
<br />lac. DATE (Mo., Dey,.yo
<br />April 22, 2016
<br />STATE
<br />On
<br />Nebraska
<br />17b. Zip code
<br />68801
<br />a 00001*bUDR0 to 44*D4D readltingla the3lndarlying cruse city
<br />PART
<br />to. WAS M EXAMIN
<br />OR CORON R.CONTACTED?
<br />0 YES NO
<br />on to death
<br />onset to derith
<br />1c. WAS AN AlJTOl PEFtP01274I0127
<br />0 YES iI NO
<br />214, WERE AUTOPSY FINCHNOS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH7
<br />0 YES ' NO
<br />22b,
<br />2,2e, PLACE OF 1820RY-A1 hem*, 'Nam, greet ry,
<br />o unding,
<br />22d. INJURY AT WORK?
<br />. 0 7119 ONO
<br />2241,0CATION OF INJURY STREET & NURSER, APT. NO
<br />*s.
<br />TE SIGNED (Mo., DeY. Yr.) 2
<br />k1 (4 k
<br />aid. To my knowledge, death OCDADDID at the time, date rsitil place
<br />a 9 el stated, (Signature and Ti el
<br />i/113.4439090 USE
<br />ONO
<br />22e, DESCRIBE H I URY 000
<br />I TO THE DEATH7
<br />LY 0 UNKNOWN
<br />orrerrowN::ni::
<br />Q
<br />28a. HAS °ROAN EIRTISSDE DONATIONBEEN.:CONSIDERED/
<br />0 TES • - 1. 1, No •
<br />TIF1ER (Type or Print)
<br />STATE
<br />24/4 TIME OF DEATH
<br />UNCED Day, Yr.) 24d,
<br />24e, On the battle of examination and/or investigation, *0 *0*)' opinion death oceurred•
<br />et the time, date and place and due the causeiel *teed, (SIDnahlre and
<br />291), WAS CONSENT GRANTED?
<br />0cabto It 26a 1. 40 0 YES NO
<br />a)tj cvftal
<br />28 DATE FILED BY REGISTRAR No., Def., Yr4
<br />
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