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<br />'WHEN; ` TFI/S 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 /J
<br />DATE OFISSIIANCE RUSSELL FOSLER
<br />1211$/2019 "020000g ASSISTANT STATE REGISTRAR
<br />4 s DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH'
<br />d
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />William K Edwards
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 31, 2011
<br />4. CITY AND STAI`E OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Superior, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506-30-4466
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />79
<br />p 8b. FACILITY -NAME (If not Institution, give street and number)
<br />Tiffany Square Care Center
<br />a/
<br />« 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. izez,.oEncE avvrr.
<br />E Nebraska
<br />9d. STREET AND NUMBER
<br />223 S. Kimball St
<br />. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ 00A
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (MO , Day, Yr.)
<br />August 5, 1931
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />0 Hospice Facility
<br />"..".r.: oUNTY
<br />Hall
<br />•Q C*T: JP.T7wr•S
<br />Grand Island
<br />8d. COUNTY OF DEATH.
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS"'
<br />12 YES ❑ NO
<br />g 1Qa. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />iS b
<br />❑ Married, het separated ❑ Widowed ❑ Divorced 0 Unknown
<br />E . 11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Clifford H Edwards
<br />10b.NAME OF:SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Carmelita Rose
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Myrtle Mary Kline
<br />z. 11 EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />1 16a. EMBALMER -SIGNATURE
<br />to
<br />5
<br />6. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />❑ Cremation ❑ Entombment
<br />❑Remoiral -;❑ Other (Specify)
<br />14a. INFORMANT -NAME
<br />Carmelite Edwards
<br />Patricia R. Curran
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16b. LICENSE NO.
<br />1092
<br />16c. DATE (Mo., Day, Yr.)
<br />April 4, 2011
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />t 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />c Curran Funeral Chapel. 3005 S. Locust St.. Grand Island. Nebraska
<br />u
<br />CITY / TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />174, zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions, and examples)
<br />s of
<br />of v.
<br />1a. PART I. Enter the chainevents- -diseases, injuries, or complications -that directly caused the death. QO NOT anter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricularfibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one eeuas.on a line Add additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />a) Renal Failure
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />fit death#
<br />Sequentially Itat conditions, if
<br />any, leading to the;esusa Baled:
<br />Enter the UNDERLYING CAUSE
<br />451sease os injury -that Initiated
<br />the events rnwltng
<br />tAstl
<br />in (Wath)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Obstructive Uropathy
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />6 Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Bladder Cancer Transitional Cell
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Diabetes Mellitus,hypedension , Hypothyroidism, Coronary Artery Disease
<br />20. IF; FEMALE:
<br />0 Not Regnant within past year
<br />❑ Ptegrwrlt at time of death
<br />Not pmgnant,:10* Pregnant within 42 days ofr before death
<br />death
<br />❑ NM pregna. but pregnant 4� days toy 1 yea
<br />❑ Unknown If pld4piadt will N the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />21b. IF "TRANSPORTATION INJURY
<br />© Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Otter (Specify)
<br />onset to death
<br />2 Years
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<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 />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />tpd. tNJURY AT WORK?
<br />;:ys YES ONO
<br />tvt>
<br />*4f. LUQAUUN Oe IrvjUlii Sfit!#:itik Nut.W i
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />2e. DESCRIBE HOW INJURY OCCURRED
<br />N
<br />M
<br />•
<br />R 0
<br />W J
<br />CI z
<br />23*. DATE OF DEATH(Mo., Day, Yr.)
<br />March 31, 2011
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />March 31, 2011
<br />ArPcrvtr - t I tri l'OW4 STATE
<br />23c. TIME OF DEATH
<br />01:00 AM
<br />3d. To the best of my knowledge, death occulted at the time, date and place
<br />and due to the causes) stated (Signature and Title)
<br />Ryan D. Crouch, DO
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES Ea NO 0 PROBABLY 0 UNKNOWN
<br />24a. DATE, SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br />the time, date and place and due to the causes) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES i7
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, :v4
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo.,:paya!r.)
<br />April 1, 2011
<br />CD
<br />OD
<br />I
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