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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
<br />1( tete1.as
<br />"42 V"Ill
<br />DATE OF ISSUANCE
<br />1/4/2017
<br />LINCOLN, NEBRASKA
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<br />STANLEY S. COOPER
<br />202201835, ASSISTANT DEPARTMENT HEALTH AND
<br />AR
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF'HEALTH IAND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Lewis Worrell Hilligas
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr,)
<br />December 19, 2016
<br />4. CITYiANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Marquette, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508-30-4622
<br />5a. AGE - LastBitthday.
<br />87
<br />8b. FACILITY.NAME (If not Institution, give street and number)
<br />Edgewood Vista Grand Island
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9S RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER"
<br />2520 West Anna
<br />9b. COUNTY
<br />Hall
<br />514. UNDER..1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />DAYS
<br />Q
<br />DOA
<br />st.cirYORTOWN
<br />Grand IIsland
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Day, Yr:);;
<br />November 19V4929"'::::
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />® Other (Specify)ASSISTED i.IV#NG
<br />0 Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />8g. IFISIDE CITY LIMITS:'
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />0 Married, but separated', 0 Widowed 0 Divorced 0 Unknown
<br />11. FA`tHERS NAME (First, Middle, Last, Suffix)
<br />Fred Emmett Hilligas
<br />13 EVER IN U.S. ARMED:FORCES? Give dates of service if Yes.
<br />(Yes, No or wok.) Yes 1;:12/28/1950-12/03/1954
<br />10b. NAME OF SPOUSE.(First ,Middle, Last, Suffix) If wife, give maiden name
<br />Shirley Killhant
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Laura Lena Belle Holcomb
<br />14a. INFORMANT -NAME.
<br />Shirley Hilligas
<br />14b. RELATIONSHIP TO DECEDENT.
<br />Spouse
<br />45, METHODOF:DISPOSITION
<br />El Burial ] Donation
<br />0 Cremation 0 Entombment
<br />❑ Removal ;❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Aofel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />16b. LICENSE NO.
<br />1191
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />16c. DATE (Mo Day, Yr.) J.
<br />December 23, 2016
<br />10:PART t. Enter the<Chalnerevelns- diseases, injuries, or complications that directly caused the death. DO'NOT enter 'Jeanine! events such as cardiac arrest,
<br />respiratory arreet, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line Add additional lines N necessary.
<br />IMMEDIATE CAUSE: •
<br />IMMEDIATE CAUSE (Final a) Respiratory Failure
<br />disease or condition resulting
<br />in. death)
<br />Sequentially lift C9ndittons if
<br />any, tending to the causd listed
<br />on
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Parkinsons Disease
<br />DUE TO, OR A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />;disease or injury that indi(0)30:,.
<br />the events reeuitingin death C DUE TO OR AS A CONSEQUENCE OF:
<br />'LAST'::
<br />d)
<br />STATE
<br />Nebraska
<br />APPROXIMATINTERVAL:.
<br />onset to death
<br />1 Day
<br />onset to death
<br />10 Years
<br />onset to death
<br />onset to death.::
<br />•
<br />18`PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Dementia
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />DYES ®NO
<br />W
<br />W
<br />U
<br />0.
<br />E
<br />142 0
<br />O
<br />a
<br />20. IF FEMALE:
<br />0 Not ptegnard Within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant:but pregnant within 42 days of death
<br />❑ Not pregnant, pet pregnant 43 days to 1 year before death
<br />❑ Unknewn if pregnant witittnthe past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. JNJURY Al WORK? s
<br />❑YES ❑NO
<br />21a. MANNER OF DEATH
<br />El Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. W TRANSPORTATION INJURY
<br />Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?:
<br />❑ YES El 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 />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 19, 2016
<br />2-30 UA1E 0iGNE 0 (Mo., Day, Yr.)
<br />December 28 2016 10:55 PM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Isaac J. Berg:;:; MD
<br />CITYITOWN
<br />23c. TIME OF DEATH
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, M my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ONO
<br />25.13(D TOBACOO USE ..NTRIBUTE TO THE DEATH?
<br />DYES NO ❑ PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Isaac J. Berg, MD,, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803
<br />28a, REGISTRAR'S SIGNATURE /I-
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES
<br />28b. DATE FILED BY REGISTRAR(Mo.,:Day Yr.)
<br />December 29, 2016
<br />
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