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<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 if
<br />DATE OF ISSUANCE
<br />201907113 INTERIM AVIZALL STATE REGISTRAR
<br />7/25/2018 DEPARTMENT OF HEALTH
<br />LINCOLN, NEBRASKA AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH`
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />William Roy Holloway
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />July 4, 2018
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Aurora, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-52-3413
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />75
<br />8b. FACILITY -NAME (if not Institution, give street and number)
<br />CHI Health; St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />3612 Catfish Ave
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatlent
<br />❑ DOA
<br />9C. CITY OR TOWN
<br />Grand island'
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />August 4, 1942
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />0 Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />II
<br />41
<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 />Betty Ann Nolan
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Rov William Holloway
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yee, No, or Unk.) NO
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ;>❑ Other (Specify)
<br />112. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Valetta Grace Marvel
<br />14a. INFORMANT -NAME
<br />Betty Ann Holloway
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />16b. LICENSE NO.
<br />1454
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16c. DATE (Mo., Day, Yr.)
<br />July 10, 2018
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />CITY /TOWN
<br />Westlawn Cemetery Grand Island
<br />17a. 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 />STATE
<br />Nebraska
<br />17b Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />13. PARTE Enter the: chain of events- -diseases, Injuries, or complications -hat directly caused the death. DO NOT entertemiinal *vents such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Etter only tato cause': on a line. Add eddalonal lines t necessary.
<br />IMMEDIATE CAUSE:
<br />a)Acute Myocardial Infarction
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />in death)
<br />Sequentially get cattditidns, if
<br />any, leadirm to the taut* hated`
<br />on linea.
<br />« Enter the UNDERLYING CAUSE
<br />o (disease or Injury Mat Initiated
<br />the events resulting in death)
<br />LAST
<br />41
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />24 Hours
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Coronary Artery Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />0)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />20 Years
<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 IRNO
<br />20. IF f EMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of Wath
<br />❑ Not pregnant, ;but pregnant within 42 days of death
<br />0 Net pregnant, but pregnant 43 days to 1 year before death
<br />0 Unkn wn I pregnant within the past year
<br />.9 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />te
<br />E
<br />0
<br />v 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />1
<br />O
<br />2d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Garver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other(SP•igy)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<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 />u z
<br />e 4 o
<br />to E M
<br />o
<br />E
<br />Q.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July4,2018'
<br />CITY/TOWN
<br />STATE ZIP CODE
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />July 19. 2018
<br />23c. TIME OF DEATH
<br />07:16 AM
<br />3d. To the best of my knowledge, death oeeuned at the time, date and place
<br />and due to the cause(s) stated (Signature and 1111e)
<br />John A. Vsiagoner, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES AAI NO ❑ PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />x w
<br />B w Z 24e. On the basis of examination and/or investigation, In my opMion Wath occurred at
<br />p the time, date and place and due to the cause(s) stated. (Signature and Tide)
<br />8
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES El NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />John A. Wagoner, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />128a.REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />July 19, 2018
<br />
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