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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATS 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 REC �r
<br />DATE OF ISSUANCE
<br />NOV 082018
<br />LINCOLN, NEBRASKA
<br />201807646
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
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<br />HHS -61 11/03 (55061)
<br />1 DECEDENT'S•NAME (First, Middle, Last, Suffix)
<br />Darlene. May Neighbors
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />July 16, 2009
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<br />-x41Z2..17.
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE -Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Prosser, Nebraska
<br />(Yrs.)
<br />72
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />May 10, 1937
<br />SOCIAL SECURITY NUMBER
<br />500 40 4931 505-42-5424
<br />8a. PLACE OF DEATH
<br />UDSPErm: N Inpatient QIER: ❑ Nursing Home/LTC ❑ Hospice Facility
<br />Fes.
<br />fIIF.
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />St. Francis Medical Center
<br />❑ ER/Outpatient 0 Decedent's Home
<br />0 004 0 Other(Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
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<br />9a RESIDENCE -STATE 19b. COUNTY
<br />Nebraska I Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d STREET AND NUMBER
<br />1823 N Custer Ave.
<br />Be. APT. NO
<br />91. ZIP CODE
<br />68803
<br />99. INSIDE CITY LIMITS
<br />NI YES ❑ No
<br />..
<br />10a. MARITAL STATUS AT TIME OF DEATH 21 Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) II wife, give maiden name.
<br />Dennis L. Neighbors
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />LeRoy Otto
<br />12, MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Anna Theen
<br />13. EVER IN U.S. ARMED FORCES? Glve dates of service II yes.
<br />(ves,no, orunk.) NO
<br />14a. INFORMANT -NAME
<br />Dennis L. Neighbors
<br />14D. RELATIONSHIP TO DECEDENT
<br />Husband
<br />15, METHOD OF DISPOSITION
<br />❑Burial ❑ Donation
<br />16a. EMBALMER -SIGNATURE
<br />( Not Embalmed )
<br />16b. LICENSE NO.
<br />18c. DATE (Mo., Day, Yr.)
<br />July 17, 2009
<br />®{Cremation 0 Entombment
<br />Li Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Service, Gibbon, Nebraska
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<br />17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, Stale)17b,
<br />Kleine Funeral Home, 3213 Si North Front St., Grand Island, NE
<br />Zip Code
<br />168803
<br />''.;:il ve+ a L'''+ :. Iat 4' L 'u i Tag #
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<br />18. PART 1. Enter the chain 01 events --diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE(Final J r M 1 ! -)',Gi ( � . all r 3-.4b 0/1I Al j
<br />_
<br />disease or Condition resulting ' DUE TO, OR AS A CONSEQUENCE OF: I one to death
<br />In death),
<br />Sequentially listaondhions, If (b) I _
<br />any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF', i onset to death
<br />on line a.
<br />EnterlheUNDERLYING CAUSE
<br />(disease orin)ury that Initiated (0)
<br />theeventaraeelgrlglndeath) DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />LAST
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<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Condlllons contributing to the death but not resulting in the underlying cause given In PART I.
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<br />19. WAS MEDIGAL EXAMINER
<br />OR CORONER CONTACTED?
<br />(`9VES ❑ NO
<br />20. IF FEMALE:
<br />II Not pregnant within past year
<br />V�❑Passenger
<br />0 Pregnant at lime of death
<br />21a. MANNER OF DEATH
<br />Natural ❑Homicide
<br />0 Accident Pending Investigation
<br />219. IF TRANSPORTATION INJURY
<br />❑Driver/Operator
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />D Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown 11 pregnant within the past year
<br />0 Suicide ❑ Could not be determinetl.
<br />❑ Pedestrian
<br />: ❑Other(9pecily)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />❑ YES 00
<br />22a. GATE OF INJURY (Mo., Day, Yr.) j 22b, TIME OF INJURY
<br />1 22c. PLACE OF INJURY -At home. farm,
<br />street, factory, office building, construction
<br />site, etc. (Specify)
<br />22d INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY -STREET & NUMBER, APT. NO. CITYROWN STATE ZIP CODE
<br />T�fs
<br />23a.DATE OF EAT (M Day, Yr.) zr
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />1 24b. TIME OF DEATH
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<br />23b. D E I ED/Mfo..(Day, Yr.)
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<br />23c. TIME OF DEATH vso
<br />AMO m ao.:it Z
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
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<br />°u c° 23d To the be .1 owl: dge, death occu red et the time. date and place °o w Z
<br />+s and .., t. •: cau e( stated. (Signature and Title ) • -� o 6
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<br />24e. On the bests of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title ) •
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<br />25. DIDTOBACCO ' ONTRR UT- TOTHE0 ATH?
<br />❑ YES ■ i ❑ PROBABLYUNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />./NO
<br />27.NAME TIT a ADDRESS OFCERTI' E HYSICIAN, CORONER'S PHYSICIAN OR COUNTTORNEY) (Type or Print)=
<br />Trav Hageman, MD, '7.29 N Cust .r AVP.. Grant) T,
<br />land NF. 611A01
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<br />29a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JUL 2 0 2009 I
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<br />HHS -61 11/03 (55061)
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