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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HE,4LTI't
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSI Of(Y.
<br />DATE OF ISSUANCE
<br />05/13/2014
<br />EQV/ICES, IT CERTIFIES
<br />RtfEALTe ND
<br />201906537
<br />LINCOLN, NEBRASKA IMAN.SEIR
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN $50116? ti`74 t,
<br />CERTIFICATE OF DEATH
<br />;02334
<br />To be completed/verified by: FUNERAL DIRECTOR
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Constance Louise Curtis
<br />2 SEX i i ±
<br />Female' °.
<br />P. ¢ATsbdFDE11TH (Mo. Day, Yr.)
<br />, _ May 7; 2 I+i✓ '` "
<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 t DAY •-;
<br />4 -DATE OF BIRTH (Mo., Day, Yr.)
<br />Litchfield, Nebraska
<br />(Yrs•)
<br />65
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />July 22, 1948
<br />7. SOCIAL SECURITY NUMBER
<br />507-66-1890
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (i not Institution, give street and number)
<br />Saint Francis Medical Center
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (SPenify)
<br />8c. CITY OR TOWN OF DEATH (Include ZIp Code)
<br />Grand Island 68803
<br />_
<br />8d. COUNTY OF DEATH
<br />Hall
<br />6a. RESIDENCE -STATE
<br />Nebraska
<br />6b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1115 South Eugene Street
<br />Be. APT. NO.
<br />IN. ZIP CODE
<br />68801
<br />9g. INSIDE CITY UMTS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 WIdowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Raymond L Curtis
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Ardith Siegel
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Loretta Hansen
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Raymond L Curtis
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Mark Higgins
<br />18b. LICENSE NO.
<br />1142
<br />16c. DATE (Mo., Day, Yr.)
<br />May 12, 2014
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Litchfield Cemetery Litchfield Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Higgins Funeral Home, 321 0 Street, PO Box 323, Loup City, Nebraska
<br />17b. Zip Code
<br />68853
<br />CAUSE OF DEATH (See Instructions and examples)
<br />To be completed by: CERTIFIER I
<br />18. PART I. Enter the chain of events--dlwaaa, injuria, or complicatlons4hat directly cursed the death. DO NOT enter tanninsl events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional linea If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Sepsis Syndrome
<br />disease or condition mulling
<br />onset to death
<br />4 Hours
<br />in de.N) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially net conditions, N b) Cerebrovascular Accident
<br />any, leading to the cause listed
<br />onset to death
<br />Chronic
<br />en"' DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />injury that initiated
<br />onset to death
<br />(disease or
<br />me WWI 1esurong In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing 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 />20. IF FEMALE:
<br />® Not pregnant within past year
<br />❑ Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident ❑ Pendine investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Drlver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown If pregnant within the past year
<br />❑Bestride 0 Could not be determined
<br />0 Pedestrian
<br />❑ Other (may)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction 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. CITY/TOWN STATE ZIP CODE
<br />S
<br />ig
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 7, 2014
<br />E
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />11:38 PM
<br />�'
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />. To the bast of req knowledge, death occurred at the lira. date and pia
<br />E Title)
<br />(
<br />s
<br />On the bate of examination andlor investigation, In my opinion dasthh occurred at
<br />due to the est Tie.)
<br />and due to tis ausep) stated. (Signature and
<br />F
<br />lig24s.
<br />the ties, date snd place ani ausets) eteM. (Signaluw
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR
<br />❑ YES ® NO 0 PROBABLY D UNKNOWN ❑ YES
<br />ISSUE • • ATION BEEN CONSIDERED?
<br />0 NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable N 26a is NO ❑ YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />28a. REGISTRAR'S SIGNATURE Aa ri„
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 13, 2014
<br />
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