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EM
<br />OF N
<br />WHEN iYIIIS COPY CARRIES THE RAISED SEAL QF THE STATE OF NEBRASIG4, -
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<br />CER7i�=YES :THE DOCUMENT BELOW TO BEA TRI.UE COPY ,.. OF THE ORDINAL RECORD I
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<br />ON FILE: WITH , ,THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />.. .'
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<br />CORDS OFFICE, WHICH /S 7YfE LEGAL DEPOSITORY FOR V1TA11�11,L RECORDS
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<br />GATE bf iSSIIA U+CEE ::1:11 iJ '' 2 1 ". RUSSELL FOSLER`
<br />1212$: 0't 8 ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA DEPARTMENT OF HEALTH
<br />1.AND HUMAN SERVICES
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALT) ANIS HUMAN SERVICES 11
<br />CERT#FCATE<t3F TETH .:; ..:..
<br />X.
<br />1. DECEDENTS -NAME; {First Middle, Last, Suffix)
<br />L SEX -
<br />& DATE OF OEATH (Mo., Dir, Yr.)
<br />..
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<br />I'll
<br />11.Eidon
<br />Lena " MCCar4esss "
<br />Male
<br />1$ 18
<br />CIT1
<br />ST14i E f}R T RiTORY, OR FOREIGN COUNTRY OF BIRTH
<br />6a. AGE -Last $i }5day
<br />. UNEIM 1 YEAR
<br />tic. UNDER 1 DAY
<br />6. GATE {iR BIR t#t.(1Ao i'tl x t, .:;
<br />.11:AND
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<br />I-1
<br />Mt)S.
<br />PAYS
<br />HOURS
<br />MINS.
<br />Nebraska . :. ,
<br />8311
<br />:193
<br />I
<br />11Arloid
<br />T SOCIALSECURITYiVUMBER `"
<br />I 11
<br />8a. PLACE OF DEATH
<br />507-48-4182
<br />HO�AL Rl Inpatient OTHER ❑ Nursing Hot�.TC ex f i(Ity
<br />,de"s
<br />b Fl1GILITY NAM (#f not institution, sire street acrd number)
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<br />❑ E(tlOtttpai>f ❑ D Nome .,iil
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<br />CAllaway Distift.' ospita)
<br />- �+► ❑ (sl�h) ....
<br />4
<br />Sc. CITY OR TOWN OF DEATH (Include Zip-: ode)
<br />Sd. C.OtiNTY OF DEATH .
<br />10
<br />Cali v 68$25 ,
<br />,^.:.tar
<br />Bs Rtr$if)ENCE�TATfre
<br />8b. COUNTY ►c. GI rY OF2 TOWN ":
<br />Nebras(ca
<br />Custer Broken t5aw` . . ;..:
<br />9d, STREET AND NUMBER . APT. NO.
<br />9f.21P GODS . . "
<br />9g. 1001v '"
<br />a41 Narth 16ftt aye
<br />68i32a
<br />®YEs p NO
<br />Etta MAt1tTAL $ IATUS AT TIME OF DEATH ® Married ❑Never Married
<br />#eb. NAME QF S80USB (Fust11 Middle, Last, Sttfflx) E wNe, give amddart Hales
<br />i:0.1"", blit ie1.paratcti, ©Widowed ❑Divorced ❑Unknown
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<br />Crrrnle AApane ::
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<br />I 4,
<br />FA PtF-R S- ARAE" (First,' `' ddle, Last, Suffix)
<br />yL 4i6THE*S-NAME (First, Mddle, Maiden
<br />f11.
<br />Melvin LeRov McCandless
<br />Ruby Pearl Peterson
<br />$T
<br />t3 EVttN U S' ARMED FORCES? Give dates of servidw irYes.
<br />14a INFflRMltiNT-NAME :
<br />94b R19i ATICEN$HIP Tia T
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<br />(Y@s. Nen cr 4 4.4 (�.fa „
<br />Connie M: C rldte s
<br />1S MgTHI.... €71SPOSITICNI
<br />16a, EMBALMER -SIGNATURE
<br />iBt LICENSE NO.
<br />19c. DATE jMo„ tai Yr.)
<br />❑ Burial © Donation
<br />Not Embalmed
<br />December 20,2018
<br />® on 'a' 1fDn1bTrlep-
<br />I'll16d,
<br />❑ftemrfral} Ofher($pecltyj
<br />CEMETERY, CREMATORY OR OTtiER.40CATiON CITU l TOWN STATE
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<br />Broken Bow Cemetery Broken BOW iieiitaSke
<br />17a FLtN>~RAL ...OMB NA-0i1E AND: MA141Nti ADDRESS (Street Clty or Town, State)
<br />9Tb, Cods
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<br />Gayler &others "MorEuarv. Inc.. 5dZ South 9th,`PO Box 665. Broken Bow. Nebraska
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<br />1$ PAIiT7 Enkrdig:sAatmofevai its--eiiseases,tr�uriea,orsanplicaaons-thatdirectlyeausatlthetleattkDDNOTens@runt{-0. o such ascardlaearrest, , APPROOfiUl4AT ',
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<br />re girateuy errs ofNutoNfar.dttrHkrticn witiious siwwlne tai 6dotOgY• D© NOT ABBRBriA:TE. eater only erre cause au a Ilne: Atld additienal tinea N necessary: ' , :: ...
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<br />IMMEDIATE CAUSE: i o test to a"
<br />.: ,,.
<br />- DIiTECAUSE (Forel a) Prolong Hypoxia ; $ Hours
<br />i0'
<br />. disease orcoedldon remu ! , ., _ ..,,.
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<br />"
<br />lm.aeattit DUE TO, OR A8`A CONSEQUENCE OF: �fi�ith
<br />1.i3ea-... t.. s... on?7ateterM .b)Right Sided Congestive Heart Failure ; d Days
<br />am iaiidinp to dig Carie Iigtaa
<br />onone a.
<br />'' DU - 11E TO, OR ASA CONSEQUENCE OF: : to
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<br />FMK ene.Uh09RLYINB CAUSE c)Su(aendocard al Myocardial Infarction ; 5 Dayr#i
<br />Is
<br />itis ewpts rasrgditg deadn) ; .DUE i0, OR A8 A CONSEQUENCE Of: iineet tRb
<br />I 1.,
<br />d or+2nary } rtttry Atherosclerosis e 1 hen to Veafta
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<br />,
<br />1S, PART II OTHER SIGNIFICANT CONDITIONS-Condidom; contributing to the death but not resulting In the underlying cause given in PART
<br />I. 19. WAS MEDICAi. EXAMiWA
<br />Chronic:, n 131st3ase:;ChtfariicAtriai Fibrillation, Diabetes Mellitusl'ype2 Cop
<br />OR CO EIRt3k�4J1Att1'E�
<br />11..
<br />I.+v
<br />Q
<br />IPH`EMALE ;;
<br />newpreanaet wldae pest yew
<br />21a. MANNER OF i STH
<br />® Naturaf ❑ Homicide
<br />21b IF YRANSPORTATiON NAIUR 21c
<br />' ❑ odvedowa.
<br />WAS IUd AUInPB� P'E IYI
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<br />L 1 Prmpna crams of"o : ",: :
<br />'� A.+.:.aatt : u `unaing mvesdee$tin
<br />[Ifeas,tutr. :""'
<br />iii
<br />.�'I!O' .
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<br />Not ar'o9n ,liar per m t wahie a2 days of death
<br />.111.1
<br />❑Suicide ❑Cdu140nibedalmmined
<br />Pedeserkn Ptd.
<br />: MDfdINi A1tAI[x�K,
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<br />(� Not pregmattG cut pcagtrem # days ro 1 Year before death
<br />❑ onwispecmy)
<br />GA u i ` -
<br />Q ttnknnwp d pn epnant wit#iln the past YearxxU:
<br />1�T1CONiP1.LTE
<br />{ Q NO
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<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />M. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office buiding, sem, dc. (Specify)
<br />If1 tURY ATW{9RK? ;
<br />.100CFSBE NOWINJURY OCCURRED
<br />❑YE8{;#)O
<br />✓i'..
<br />22f. LOCATION
<br />OF INJURY - STREET 8 NUMBER, APT.NO. CITY/TOWN STATE 23P CODE
<br />e<
<br />23tt DA7 OFC Aiff {Mo., Day, Yr.}1.
<br />>_ Us. DATE SIGNED (Mo., Day, Yr.)
<br />is
<br />24b. T7N� OF DFATM
<br />': ,
<br />De4erf�. 18, 2018
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<br />I i23b.
<br />DATE SIt3l1ED (Mo , Day, Yr.)
<br />. jilt r " .
<br />23c. TIME OF DEATH
<br />1:0 M'
<br />> 24c. PRONOUNCED DEAD (Mo., Day, Yr.
<br />W. TUM PRONOUND�£i DEAD
<br />3tl. To due bast of my knox4edge, death occurred at the Cane, date and place
<br />z Yoe. On the bask of easndnadmi and/or Invesdg n, Way assumed it
<br />2
<br />/
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<br />and due totlm causes) stafed. p4pawre and Title)
<br />O, thedme date and Plea and due to db cause(s) adki qqd Tek)
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<br />.1.
<br />1 t}rt (1 Loper, M}? :.
<br />$ q :
<br />f11, r
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<br />. 5. DIEi TOSiIAC
<br />I« .:, _ ::.:
<br />UBE:C(IiJTRti#UTE TO THE OEATH9 26a HAS ORGAN:BR Tl89UEDOttA7IAN'tEEN CONSIDERED?
<br />. ..:
<br />36b. WAS ENT ire ::
<br />❑ YES Ib! NO ❑ PROBABLY ❑ ,UNKNOWN ®YES ❑ NO
<br />Not Applicable If 26a Is NO YES NO
<br />NA E, E AN A E CERTIFIER {Type or Print)
<br />{
<br />K(r4f1#ttt Lot,..IVID, 211 'E Kit»Eiaif PCS Bats 129, CaliaWay, (%ebraska 68825
<br />2$a ..000, SIGNATURE SIt tAT4 RE .11 1.2s
<br />.DATE FILED BY REGISTRAR SAMA., {Say, Yr)1.
<br />{,A .
<br />' :.
<br />-11
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<br />December 28, 2018 ,
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