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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF tIFILAFAX
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NES
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY ,F016(/s
<br />, IT CERTIFIES
<br />AND
<br />DATE OF ISSUANCE
<br />08/25/2010
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN.SERVICES<^;
<br />CERTIFICATE OF DEATH
<br />202109044
<br />To be completed/verified by: FUNERAL DIRECTOR I
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Donald Ralph Fillinger
<br />2. SEX
<br />Male
<br />3. DATE OF. DEATH (Mo., Day, Yr.)
<br />August 15, 2010
<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 />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Greeley, Nebraska
<br />(Yrs.)
<br />73
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />July 11, 1937
<br />7. SOCIAL SECURITY NUMBER
<br />505-38-5702
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />425 E. 20th St.
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA ® Other (Specify)Daughters Home
<br />8c. 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 />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />104 E. 12th St.
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ 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 />Marjorie Ann Pokomey
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Oswald J Fillinger
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Arlene Murphy
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or unk.) Yes 06/06/1956-04/10/1959
<br />14a. INFORMANT -NAME
<br />Marjorie Ann Fillinger
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />tEl Burial 0 Donation
<br />1k. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />1eb. LICENSE NO.
<br />1071
<br />16c. DATE (Mo., Day, Yr.)
<br />August 19, 2010
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />To be completed by: CERTIFIER
<br />ill. PART I. Enter the chain of events- -diseases, in)uriea, or complications -that directly caused the death. DO NOT enter terminal 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 one line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Heart Failure
<br />disease or condition resulting
<br />onset to death
<br />Immediate
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b) Heart Bypass
<br />any, leading to the cause listed
<br />onset to death
<br />Years
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that initiated
<br />onset to death
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Condltlons 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 />Q Not pregnant within past year
<br />Q Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />Q YES ® NO
<br />Q Not pregnant, but pregnant within 42 days of death
<br />Q Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown it pregnant within the past year
<br />0
<br />Q Suicide Q Could not be determined
<br />0 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, 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 />E W
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />To be comps by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />August 18, 2010
<br />24b. TIME OF DEATH
<br />05:54 PM
<br />IY
<br />E w i
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />August 15, 2010
<br />24d. TIME PRONOUNCED DEAD
<br />05:54 PM
<br />3 g
<br />2
<br />o II
<br />29d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s)use(s) stated. (Signature nd Title)
<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 cause(s) stated. (Signature and TNN)
<br />Barbara Dunn, Hall Deputy County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO 0 PROBABLY ® UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />D YES ®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 (PHYSICIAN, PHYSICIAN
<br />Barbara Dunn, Hall Deputy County Attorney, 231
<br />ASSISTANT, CORONER'S PHYSICIAN OR COUNTY A
<br />S. Locust, P.O. Box 367, Grand Island, Nebraska,
<br />ORNEY) (Type or Print)
<br />68802
<br />r
<br />28a. REGISTRAR'S SIGNATURE J� !��-_
<br />,/p�v
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />August 18, 2010
<br />
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