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STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1. DECEDENT'S -NAME (First, Riddle„
<br />Je Eu ene Davis
<br />4. CRY AND STATE OR TERRITORY, OR FOREIGN COUNTRY 0
<br />Last, Sulllx)
<br />CERTIFICATE OF DEATH 360207
<br />Bassett, Nebraska
<br />BIRTH
<br />6a AGE -Last Birthday
<br />efm.)
<br />68
<br />fb. UNDER 1 YEAR
<br />2.SEX
<br />Male
<br />50. UNDER 1 DAY
<br />MOA DAYS
<br />HOURS
<br />MMA
<br />3. DATE OF DEATH (Mo.,Day,Yr.)
<br />November 29, 2015
<br />0. DATE OF BIRTH (Mo., Day, Yr.)
<br />April 16, 1947
<br />7. SOCIAL SECURITY NUMBER
<br />507-56-4223
<br />8b. FACLITY-NAME Of not Institution, gale street and nuMber)
<br />VA Medical Center
<br />12. PLACE OF DEATH
<br />OSOBIRLI ® Inpstlent
<br />❑ ERIOutpstlent
<br />❑DOA
<br />=MO O Noising Hoene/LTC ❑ Hospice FadIRy
<br />❑ Decedent's flame
<br />❑ Other(Speeiy)
<br />Be. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 88105
<br />8d. COUNTY OF DEATH
<br />Dou . las
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9o. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />424 N. Darr
<br />9s. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CRY LIMITS
<br />®Yes El No
<br />10.. MARITAL STATUS AT TIME OF DEATH ®Manned 0 Never M • fob. NAME Off SPOUSE (Filet, Middle, Last, Suffix) S wife, glue maiden name.
<br />0 Manned, but separated 0 Widowed 0 Divorced ❑ Unimosm
<br />Connie Lee Wood
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Dale Davis
<br />12. MOTHER'S -NAME (First, Middle,
<br />LeOta Kesselhuth
<br />Maiden Surname)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of sonic. H Yea
<br />(Yes, No, or Unit.) Yes 02/15/1967-11/17/1 70
<br />14a. INFORMANT -NAME
<br />Conne Lee Davis
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />18. METHOD OF DI iPOSRION
<br />Burial ❑DonNbn
<br />❑ asmatlen ❑Entombsem
<br />❑ Mmoval ❑OIM,lepandy)
<br />189. EM
<br />18b. LICENSE NO.
<br />j05-
<br />16d. CEMETERY REMATORY OR OTHER LOCATION CITY/TOWN
<br />Grandview emetery Long Pine
<br />12 DATE (Mo., Day, Yr.)
<br />December 3, 2015
<br />STATE
<br />Nebraska
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand island, Nebraska
<br />17b. ap Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />11. PART 1. Eider 9r duanefsvmg-dorm MANNAerm50Ontlens• ANON caused lin dun. SO NOT enhrWmNW suns such r cardiac anent
<br />respirator/_,.., or vmmladr RMIY9en without showing NA stlele*y. DO NOT ABBRIVIATE. Emir only ons num ons Pm. Add WdItIonN linos N meanly.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final ^
<br />dlseorcenditlonrasultlng a) Cess (1Ah -r t(`��
<br />in death)
<br />DUE TO, OR AS A CONSEQU OF:
<br />SagwmtWy u*t conditions, I . b)
<br />!nY, WNn9 to the canai lle: Rd
<br />on line a.
<br />Ci (1 ak tr-\ P l e,(,d. \
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />4-t uses
<br />onset to death
<br />MWithS
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or Injury that Inldated
<br />the events r..ultlng In death)
<br />LAST
<br />11 �5 Ihlit RC. car' k (Ink ieU
<br />onset to death
<br />gu✓S
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />4)
<br />_MrS 14. Ars
<br />onset to death
<br />ti•vC
<br />18. PART N. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unmown If preywd within the pat year
<br />21.. R/ANNER OF DEATH
<br />,LWatued 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />❑ Suicid. 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />119. WAS MEDICAL EXAMINER
<br />OR CORONER -CONTACTED?
<br />❑ YES WO
<br />21e. WAS AN AUTOPSY PSRFORMED?
<br />❑ YES O
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22.. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY 1220. PLACE OF INJURY -At home, farm, street, factory, office building, consbuctlon site, etc. (Specify)
<br />m
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF IN.IUKY - STREET & NUMBER, APT. NO. CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />tqg
<br />3s
<br />121
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />I I- a'i- 1-<)
<br />22. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />12. - Z-15 1 0:304
<br />23d. To the boast of my Imowl.dgs, death occurred at the time, date and place
<br />7 duelo th fanieffs) stated. (Signature and MN)
<br />'Ur Cg� 1 t 1 r 0
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />24e. On the basis of examination and/or Investigation. M my opinion death occurred
<br />at the time, date and place and due to the cause(*) stated (Signature and Title)
<br />254NDyGBACCO USE CONTRIBUTE.1'O N? THE AT
<br />r}'J'!ES ..��❑IP/ AePBAELY [.UNKNOWN
<br />0.2t116vd5, f11;' ewr/woweed Ofc5RilF)ERITyp.'erPgat) --
<br />• ` 0mft-C: buotittc _ toi Wud l()Jof 't (4 -Nr• • Q✓ys!/tlxA►t
<br />28a. HAS ORGAN OR TISSUE DO,TKM BEEN CONSIDERED?
<br />❑ YES ik110
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable N 285 Is NO 0 YES 0 NO
<br />NC (0 '1uS
<br />28a. REGISTRAR'S SIGNATURE i
<br />=Al -
<br />29b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />DEC 03 2015
<br />r r;
<br />This cdriii 9this document to be a true copy of an original record on file with Vital Statistics, Douglas
<br />County Health .Dept:, Omaha, Nebraska. Certified copies must have a raised seal in the area to the left.
<br />Reproduction of this green certificate are not legal copies.
<br />DEC 0 3 2015
<br />Date Issued: g
<br />Re istrar:- _ v�
<br />
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