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STATE OF NEBRASKA WHEN THIS ' COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 11/22/2016 LINCOLN, NEBRASKA 201803447 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Albert Duane Walton 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Rural Clearfield, South Dakota 5a. AGE - Last Birthday (Yrs.) 82 5b. UNDER 1 YEAR MOS. DAYS 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) November 7, 2016 6. DATE OF BIRTH (Mo., Day, Yr.) December 1, 1933 7. SOCIAL SECURITY NUMBER 504 -3A -1809 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) O 3176 S. Blaine Street i x 8c. CITY OR TOWN OF DEATH (Include Zip Code) G Grand Island 68801 4 9a. RESIDENCE -STATE it 41 Nebraska LL 9d. STREET AND NUMBER a 3176 S. Blaine Street 2i 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, butseparated p. ❑ Widowed ❑ Divorced ❑ Unknown dr p 1 a) d Ralph Andrew Walton E 1 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk,) Yes 01/19/1952-01/18/1955 15. ^4811.1000F DISPOSITION Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) L U to IMMEDIATE CAUSE (Final disease or condition resulting in death) .. ... 9b. COUNTY Hall DUE TO, OR AS A CONSEQUENCE OF: Sequentially lktt cell;Gtions, if b) any, leading to the Cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: C) Enter the UNDERLYING CAUSE (diseaseor injury that Initiated; The events resulting: in de g DUE TO, OR AS A CONSEQUENCE OF: LAST . < 20. IF FEMALE: ❑ Not pregnantwlthinpastyesr ❑ Pregnant at time of death ❑ Not pregnant,.Out pregnant within 42 days of death ❑ Nat pregnant,bUt pregnant43 days to 1 year before death ❑ Unknewn if ptagnant within the past year 22a, DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? is ❑YES ❑NO 16a. EMBALMER-SIGNATURE Katie M. Smydra 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 25. DID TOBACCO USE CQNTRIBUTE TO THE DEATH? 0 YES fia NO ❑ PROBABLY ❑ UNKNOWN 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island 8d. COUNTY OF DEATH Hall 9e. APT. NO. Decedent's Home ❑ Other (Specify) 9f. ZIP CODE 68801 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Kathrine Ida Harris 1. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Freda E Wagner Middle, Maiden Surname) 14a. INFORMANT -NAME Kathrine ida Walton 16b. LICENSE NO. 1454 9g. INSIDE CITY LIMITS RI YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day Yr.) November 11, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 TOWN Bellwood Cemetery Bellwood STATE Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island.' Nebraska OF DEATH (See instruct ions and examples) PAR( I. Enter the Chain Of events -- diseases, injuries, or complications -that directly caused the death, DO NOT enter terminal events such as cardiac arrest, respuato,y arre3i vemricpfar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines H necessary. IMMEDIATE CAUSE: a) Supranuclear Palsy 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian Other (Specify) STATE 26a. HAS ORGAN: OR TISSUE DONATION BEEN CONSIDERED? YES ❑ NO 17b.Zpcode 68801 APPROXIMATE INTERVAL onset to death 6evei al Years onsetto'dea onset to death 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 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) 28b. DATE FILED BY REGISTRAR{Nlo., Day, Yr.) November 16, 2016 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 23p. DATE SIO,NED (Mo., Day, Yr.) November 16, 2016 23c. TIME OF DEATH 03:55 AM 23a. DATE OF DEATH (Mo., Day, Tr.) November 7 2016 U 2 t- u a - 3d. To the best of my knowledge, death occurred at the time, date and place S and due to the cause(s) stated. (Signature and Title) o Tharrlas F. Werner; MD CITY/TOWN 24e. (JATE 3ILiNt& jivio., Day, Yr.) 24b. TIME € DE.4Ttf 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES fa NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Thomas F; Werner, MD, 810 North Diers Avenue, Grand Island, Nebraska, 68803 1 28a.... REGlSTRARS SIGNATURE o I `� j JrcJ •�rV�"^