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<br />STATE OF NEBRASKA
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<br />WHEN '! THIS I' 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
<br />DATE OF ISSUANCE
<br />6/9/2021
<br />LINCOLN, NEBRASKA
<br />et,RST -
<br />2 0 2 1 0 7 8 4 2. ADE TA MENTNE HEALTH REGISTRAR
<br />SARAH BO
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />21 07198
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death, I
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Eileen Juliann Thornton
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />May 21, 2021
<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 />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />Grand Island, Nebraska
<br />(Yrs.)
<br />74
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />May 13 1947
<br />7. SOCIAL SECURITY NUMBER
<br />506.58.8346
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER 0 Nursing Home/LTC © Hospice FaciFty
<br />8b. FACIUTY-NAME (B not Institution, give street and number)
<br />1808 N Kruse Avenue
<br />0 ER/Outpatient ® Decedent's Home
<br />0 DOA 0 Other(Specify)
<br />8e. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1808 N Kruse Avenue
<br />Be. APT. NO.
<br />91. ZIP CODE
<br />68803
<br />9g. INSIDE crry UMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Chester Dean Thornton
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Ed Christensen
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Lyda Gleason
<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 />Chester Dean Thornton
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />Buda! ©Donation
<br />18a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />18b. LICENSE NO.
<br />1537
<br />16c. DATE(Mo., Day, Yr.)
<br />May 27, 2021
<br />Crematlon 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL: HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Code ,
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />1a. PART I. Enter ths chain of events- -diseases, injuries, or compautlons. hat directly caused the death. DO NOT enter terminal events such es cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or venhicular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Imes if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Pins! ::- a)Unknown Natural Causes
<br />dlsuea Of cenfaion reRdafng
<br />In Ankh)
<br />onset to death
<br />-
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b) Hypoxia
<br />any, wading to the Mese listed
<br />on fine a,
<br />onset to death
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enterttr,UNDERLYING CAUSE D) Chronic Obstructive Pulmonary Disease
<br />(disease or Injury that Initiated
<br />onset to death
<br />Years
<br />the events resulting In death) DUE ID, OR AS A CONSEQUENCE OF:
<br />LAST d)Type 2 Diabetes
<br />onset to death
<br />Years
<br />18.'PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />Obesity, Hypertension, Hypercholesterolemia
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO
<br />20. IF FEMALE:
<br />JNot pregnant within past .Year
<br />Pregnant aitime of (hath
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident ❑-Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY' PERFORMED?
<br />0 YES ®NO
<br />❑ Not pregnant, but pregnant within 42 days of death❑
<br />❑ Not pregnant, but pregnant 43 days to 1 year before dant
<br />unknown :winsome within tile past year
<br />0 Suicide ❑Could not be determined
<br />Pedestrian
<br />0 other (Specify(
<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,
<br />farm, street, factory, office building,
<br />construction site etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />2. LOCA11ON OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE Zip CODE
<br />ft
<br />23a. DATE OF DEATH (Mo., Day, Yr.)Z
<br />s .
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />June 1, 2021
<br />24b. TIME OF DEATH
<br />Approx. 06:30 AM
<br />F ,,
<br />o$
<br />I
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />$k
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<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />Mav •21.2021
<br />24d. TIME PRONOUNCED DEAD
<br />09:28 AM
<br />/ 2
<br />23d. To the bettor my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Me)
<br />"fez
<br />20 1 §
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<br />24e. On art basis of examination and/or investigation, in my opinion death occurred at
<br />the. time, date and place and due to the ousels) stated. (Signature and Title)
<br />Christopher J Harroun, Hall County Attorney
<br />25, DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ❑ NO 0 PROBABLY ® UNKNOWN
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO
<br />26b. WAS CONSENT GRANTED
<br />Not Applicable If 28a Is NO AYES [ NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chr stopher J Harroun, Hall County Attorney, 231
<br />S Locust St, Grand Island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATUREa�
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 2, 2021
<br />
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