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STATE OF NEBRASKA
<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 />8/13/2018
<br />LINCOLN, NEBRASKA
<br />Ard
<br />RUSSELL FOSLER DEPARTMENT HEALTH AND
<br />INTERIM ASSISTANT STATE REGISTRAR HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />t .,
<br />., 7. SOCIAL SECURITY NUMBER
<br />Ws
<br />Z. 506.. -50 -2203
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<br />m
<br />E
<br />9a
<br />z
<br />A
<br />3
<br />C.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Carol Jean Killham
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Wilcox, Nebraska
<br />8b, FACILITY -NAME (If not Institution, give street and number)
<br />CHIHealth St. Francis
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9d. STREET AND NUMBER
<br />109 West 18th Street
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME first, Middle, Last, Suffix)
<br />James Hugh Martin
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Utk.) No
<br />15, METHOD OF DISPOSITION
<br />0 Burial ' ❑ Donation
<br />E Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />Enter the UNDERLYING CAUSE
<br />(disease ds injury that initiated
<br />the events resulting in death)
<br />LAST ..
<br />20 IF:.FEMALE:
<br />❑ Notpregnatd within past. year
<br />❑ Pregnant at time of death
<br />❑ Nct pregnant, but pregnant within 42 days of death
<br />Not pre buk pregnant 43 days to 1 year before death
<br />❑ Unknown if pre gnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. I NJ)JRY AT\NORK?
<br />3a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />23c. TIME OF DEATH
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />u YES ❑ NO ❑ PROBABLY E UNKNOWN
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />78
<br />16a. EMBALMER - SIGNATURE
<br />Not Embalmed
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />Sb. U
<br />NDER 1 YEAR
<br />MOS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />E ER/outpatient
<br />❑ DOA
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />14a. INFORMANT -NAME
<br />Alford Killham
<br />170, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />v
<br />to ah
<br />F O Z
<br />+' a a 0 3d. To the beat or my knowledge, death occurred at the time, date and place
<br />C
<br />to 2 9 and due to the cause(s) stated. (Signature and Title)
<br />O
<br />: P.
<br />:�
<br />a
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ENO
<br />EGISTRAR'S SIGNATURE
<br />DAYS
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />9e. APT. NO.
<br />MINS.
<br />i8b. LICENSE NO.
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />0 Other(Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />August 6, 2018
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />August 5, 2018
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 5, 2018
<br />August 16
<br />OTHER ❑ Nursing Home /LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />9f. ZIP CODE
<br />68801
<br />28b. DATE FILED BY REGISTRAR
<br />August 10, 2018
<br />6. DATE OF BIRTH (MO., Day, Yr.)
<br />39
<br />❑ Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9g, INSIDE CITY LIMITS`
<br />I YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Alford Killham
<br />12, MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Elizabeth Dirk Driefholt
<br />14b. RELATIONSHIP: TO DECEDENT
<br />16c. DATE (Mo., Day, Yr.}
<br />August 9, 2018
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Trinity United Methodist Columbarium
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17b, Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART Enter the chain or evens -- diseases, injuries, or complications -that directly caused the death. DO NOT entertenninal events such as cardiac arrest,
<br />respiratory arrest, Of ventliCular fibrillation without showing the etiology. DO NOT ABBREVIATE, Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Acute Rupture Of Abdominal Aortic Aneurysm
<br />disease or condition resulting
<br />APPROXIMATE INTERVAL •
<br />onset to death
<br />Hours
<br />in death)
<br />Sequentially list condit if
<br />any, leadingtotlle cau(Ie Iiste:d
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />blAtherosclerotic Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />E YES ❑ NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ENO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑NO ..
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY /TOWN
<br />STATE
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />12:29 PM!
<br />24d. TIME PRONOUNCED DEAD
<br />12:29 PM
<br />24e. On the basis of examination and /or investiga ion, in my opinion death occurred at .
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />Sarah Hinrichs, Hall Deputy County Attorney '!
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Sarah Hinrichs Hall Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />Day, Yr
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