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<br />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 RECORD77S,�
<br />DATE OF ISSUANCE
<br />JUN 2 0 2019
<br />LINCOLN, NEBRASKA
<br />201904586
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND IIUMAN SERVICES
<br />STATE OF NEE)RASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPO
<br />CERTIFICATE OF DEATH
<br />Er
<br />ERAL DIRECT
<br />E
<br />1 DECEDENT'S -NAME ;(Fast,
<br />Glennys
<br />Middle. Lest.
<br />Harrite Maddox
<br />Sutlla)
<br />SEX
<br />Female
<br />3. DATE OF DEATH (Ma , Day, Yr.)
<br />September 11, 2007
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Deshler, Nebraska
<br />5a. AGE -Last Blrlhday
<br />(Yrs)
<br />88
<br />S0. UNDER I YEAR 1 Sc. L"10ER 1 DAY
<br />6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />April 18, 1919
<br />MOS.
<br />DAYS
<br />HOURSMINS.
<br />1
<br />7 SOCIAL SECURITY NUMBER
<br />505-36-6625
<br />1 Ba. PLACE OF DEATH
<br />HOSPITAL: 0 Inpatient On -ER 2 Nursing Home:tTC OHospice Facility
<br />0 ER'OutpaIient 1{7 Decedent 5 Home
<br />0 DOA ❑Dtner(speciry)
<br />B0. FACILITY -NAME
<br />Home:
<br />(If not instilullon, give street and number)
<br />1104 N. Gunbarrel Road
<br />Be. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island, 68801
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a RESIDENCE STATE
<br />Nebraska <
<br />90. COUNTY
<br />Hall
<br />9c. CITY 0570584
<br />Grand Island
<br />90. STFWET AND NUMBER
<br />1104 N. Gunbarrel Road
<br />IOa. MARITAL STATUS ATTIME OF DEATH Ci Married 0 New Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />98. APT. NO 191 ZIP CODE
<br />111 68801
<br />100. NAME OF SPOUSE [First. Middle. Last, Suffix) 11 wile, give maiden name.
<br />Kenneth Maddox
<br />9g. 1N5155 CITY 0r:1S
<br />Q YES yo N0
<br />11.::FATHER'S- NAME i': (First, Middle, Last.
<br />Conrad Seitz
<br />Sonic)
<br />12. MOTHER'S -NAME (P,rsl,
<br />Anna
<br />Middle,
<br />Maiden Surname)
<br />Hongerson
<br />13. EVER 1N U -S. ARMED FORCES? Give dales of service it yes.
<br />(Yes,no, orunk} No.I.
<br />15 METHOOOF DISPOSITION
<br />5[Burral til Donation
<br />QCremahon ❑Entombment
<br />Q Removal 0 Other (Specify)
<br />14a. INFORMANT NAME
<br />Kenneth Maddox
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />166. LICENSE NO
<br />/2
<br />145. RELATIONSHIP TO DECEDENT
<br />Husband
<br />160. DATE (Bio., Day. Yr. )
<br />September 13, 2007
<br />CITY(TOWN STATE
<br />Ft. McPherson National Cemetery, Maxwell, NE
<br />17a. FUNERAL HCME-NAME AND MAIL NG ADDRESS (Street. Cityor Town. Stale)
<br />Apfel Funeral Home 1123 West Second, Grand Island, NE.
<br />17b. Zip Cods
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />by: CERTIFIER
<br />E
<br />w
<br />18 PART 1 Enter the chain of events --diseases, injuries, or complications -that directly caused me death. D0 NOT enter terminal events such as cardiac arresh
<br />resplralory arrest, or: ventricular tibrilfalion wtlhoui showing the aliology. D0 NOT ABBREVIATE. Enler orty one cause on a hna- Add addillonat Tines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In death)
<br />Sequenilatiy$st eondllldns,'I
<br />any, leading to the cause listed
<br />on line 1.
<br />Enter the UNDERLYING CAUSE
<br />(disease ortn)ory that Initiated
<br />the events reeu5Iny In death).
<br />LAST
<br />(a) cg;/k(2- t/itI
<br />DUE T0. OR AS A CONSEOUENCE OF
<br />Cls^ t c, ct
<br />005 T0.09 AS A CONSEQUENCE OF:
<br />(c)
<br />APPROXIMATE INTERVAL
<br />onsel to death
<br />chs
<br />onset to death
<br />onset to deals
<br />DUE T0, OR A5 A CONSEQUENCE OF:
<br />1dl
<br />onset to [learn
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions conuibuting to the death but not resulting in the underlying cause given in PART I.
<br />19 WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />YES ❑ NO
<br />26 IF FEMALE:
<br />t>4*Nol pregnant wllhin past year
<br />0 Pregnant at lime 01 death
<br />0 Not pregnant, bud pregnant wilhln 42 days or death
<br />0 Not pregnant Out pregnant 43 days l0 1 year5efare death
<br />0 Unknown 'd pregnant within the past year
<br />21a.M NER OF DEATH
<br />Natural ❑Homicide
<br />❑ Accident Pending Investigation
<br />❑ Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />O Pedestrian
<br />Q Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES XNO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ N0
<br />22a. CATE OF INJURY (Mo., Day, Yr.)
<br />220 INJURY AT WORK?
<br />❑ YES 0 N
<br />22o. TIME OF INJURY 22c. PLACE OF INJURY -Al home, farm, street, factory. oltice building, construction site, elc. (Specify)
<br />I I
<br />228 DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY -STREET 8 NUMBER, APT N0.
<br />CITY/TOWN
<br />STATE ZIPCODE
<br />233. DATE.OF DEATH (Mo.. Day. Yr)
<br />O
<br />235. DATE GN'5D (Mo.. Day, Yr.)
<br />9
<br />270. TIME OF DEATH
<br />OL{vo
<br />m
<br />23d.Toif* , .est..
<br />to
<br />r
<br />my knowledge. death occurrea al the Ilme. dale and place
<br />cause(s) stated. (Signature and Title ) •
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />240.TIME PRONOUNCED DEAD
<br />m
<br />48.On the bass of eraminaiion andior Investigation. in my opinion dears occurred at
<br />Ise lime, dale and place and due to me cause(s) staled. ISlgnature and Title )
<br />25 DID TOBA C¢ USE CONTRIB' ETO THE DEATH' 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED'
<br />0 YES E1>1 NO 0 ROBABL0 0 UNKNOWN 0 YES fi NO
<br />PHYSICIAN CORONER'S PHYSICIAN OR COUNTY ATTORNEY (type Prim
<br />26b. WAS CONSENT GRANTED?
<br />Nel Applicabe 11 26a is NO 0 YES 0 NO
<br />27. NAME: TiTL AND ADDRESS OF CERTIFIER
<br />( 0 )i yD )
<br />Travis Hageman M.D. 729 N. Custer Ave., Grand Island, NE 68803
<br />2Ba. R EGISTRARS SIGNYTURE
<br />44/
<br />28b. CATE FILED BY REGISTRAR IMo.. Day, Yr.)
<br />SEP 172007
<br />
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