|
i 91g Yip
<br />ri...%. )01,141. ((!(�
<br />i1.. G)If))7r�711(I(li
<br />��+ae�lllt1111)::
<br />'�'i 1 1
<br />11AA�jII��ppy ,a rr •e 1'i
<br />tiilrll((;S SS'r/Irtfii Sr41)i1`d„i1�5�(r((I((WAa1 a (i�ililt�ti!Py3E
<br />rrnrrl11�,111itSi`ar u! ry iiYr'„\`1 (w tr r// r htlliVi`IC\1i{d.
<br />/r4(llilllii))D�t a6rN.ti,!„11y�+`. ...:_•(%lt�lllili"1.'.
<br />I 11 !I Y
<br />;,--� 11 11 I
<br />` ;r�r ry <:11\1 // it 11 •�\ 11 1.i.
<br />{ � 11 11 / > `�� ( ' 1
<br />11 11 11 / �- . t / % . 1
<br />t I 1 � � 1
<br />f / ..S 1 11 s'^ � t ( I
<br />�_, r I s
<br />1 r 1'I r � 1 I s
<br />) ,#)�31,...I.I)ff�r[htAB�At. f,,,rrAAr/!(..A1n�t1. i..t,Fm4..\, ��..Iu,urA .frr � 1
<br />a.lA4,�i)..f/E$ua„t.> ---- -- - - (A��Hllio.al 1111 / `) r
<br />)J ..�..----.._..._ _ ! 1 uri, fes [t )))`.,a
<br />V1Iila`rdQm) rrG(
<br />r,LV.rppoll Y:_ s ilitttlrlfCtl?>°�
<br />/4rAi,Ylfftr y /tfG/lI%i111`ltl�3:. .r �rnrrna;
<br />WHEN rmS COPYCARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WiTH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />ATE OFI$SUAN ._..
<br />5/312022
<br />LINCOLN, :NEBRASKA
<br />,lea..
<br />202204929
<br />oul&A 44tinke
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1 DEO.EDENTS-NAME (First, Middle, Last, Suffix)
<br />.fables Mountloy Shelton
<br />CERTIFICATE OF DEATH
<br />4. CiT\f ANI} STATE OR'i'ERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Central City. Nebraska
<br />7 SOCiAL:SE.CURITY°NUMBER
<br />547-36 18811
<br />5a. AGE Last
<br />(Yrs.)
<br />85
<br />1
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />Tiffany. Square Care Center
<br />Bc. 'GIT OR.TOWN
<br />•
<br />• Grand island
<br />ofbe4 (Include Zip Code)
<br />88803`
<br />ea. RESIDENCE -STATE
<br />Nebraska
<br />st:: SIt EETANI7: UMBE#
<br />1605 Grand avenue
<br />9b. COUNTY
<br />Hall
<br />irthday.'.
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />t r
<br />lit}
<br />'ir (yri 1 la e%0 i .110Gs-6,,v,Yr1, „il�ir�r�S�r 1,lrrbaq �
<br />.,U(((1 r r r �r�rrlt `sitrryl/ 117ri -
<br />ip1 //(I'IiT111iD1\
<br />3. DATE OF DEA'!H (Mo Dgr;'1ri
<br />March 8 2011
<br />MOS.
<br />DAYS
<br />8L:PLACE OF DEATH:
<br />HOSPITAL 3Indatlent
<br />0 ER/Ou patient
<br />0 DOA
<br />10a. MARITAL S1ATLEI#T TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknewn
<br />11 FATHER S NAME (Flretr Middle; t.ast, Suffix)
<br />Max I4aley. Steno s
<br />13. EVER list U S' ARMED FORCES?
<br />(Yes, No, or Link.) No
<br />16, METHOD OF;DISPOSITIO)V
<br />0 L trial Danatfan_
<br />EJ crematron Entombment
<br />�] i#em4wat j other $pec+fy)
<br />Give dates of service if Yes.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />DATE OF BIRTH (o.,
<br />August 4,1925
<br />OTHER ® Nursing HomeA,TC
<br />0 Decedent's Home
<br />0 Other(SpecNY)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />e, APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />Mb. NAME OF BPouse (First; Middle, Last, Surtix) If wife, give maiden
<br />Edna Johanna Heiberg
<br />12. MOTHER'S -NAME (First, Middle, Malden 'Surname)
<br />Elsie Alice .:Ouisenberry
<br />14a. INFORMANT -NAME
<br />Edna Johanna Shelton
<br />16a. EMBALMER -SIGNATURE
<br />Paul Becker
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION <'
<br />Nebraska Anatomical Board
<br />16b. LICENSE NO.
<br />1085
<br />17a. FUNERAL HOME NAME AND MA LINO ADDRESS (Street, City or Town, State)::
<br />All a)ttls Funeral Il Mme, 2929 S. Locust Street, Grand Island, Nebraska for
<br />Nebraska Ariatornicaal Board. 986395 Nebraska Medical Center. Omaha, Nebraska
<br />CAUSE OF DEATH (See Instructions al
<br />CITY / TOWN
<br />Omaha
<br />examples)
<br />16. PART I. Enter the chain of events- .dissasw, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, of ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMIEIStATECAusE [phret 6) Pancreatic cancer Metastatic
<br />disease'or condition resuahig
<br />Sequentially het conditions, if
<br />.;arty. isedingw, thecause Meted,
<br />: Er r1t)a:I/NpBRI%7hto ems.
<br />(diseaes orin)uryMat Initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />6)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d).
<br />t8 PART IJ QTHER SIGNIFICANT CONDITIONS -Conditions contributing to the Beeth but not resulting In the Underlying cause given In PART L
<br />ProataticCancer hypothyroidism,degenerative Arthritis
<br />20� :yIF FEMALE ..
<br />f J NACf+iagnaotwihlnpast•dar
<br />7 PtilgnshtatIdn*ofNaath
<br />0 foot ptegtuud tied pra8nadt within 42 days of. death
<br />0 Not pregnant; but pregnant 43 days 10 1 year hetore death
<br />,0. Unkoawn 11 pregnant within the pest year
<br />22a. qt TE O>±1
<br />URY (Mo;>1')ey, Yr.)
<br />22d, INJURY ATWORK?
<br />❑YES ❑.NO
<br />21a. MANNER OF DEATH:.
<br />RI Natural 0 Homicide
<br />0 AccldeM 0 Pending Investigation
<br />0 Suicide 0 Could snot be determined
<br />22b. TIME OF INJURY
<br />21b.IF TRANSPORTATION INJURY
<br />0 griverlOperator
<br />0 PessenQer
<br />OaPedestrlan
<br />0
<br />Other (Specify)
<br />►. €iatbl}7E' CITY t,Il rrs:;
<br />0!.0:1#.0
<br />nature,:
<br />14b. RELATIONSHIP TO DECEDENT:>
<br />Wife
<br />6c. DATE (MC, . Degi :Yf.)
<br />March 9. 201
<br />ITh ,Ztis.Code ;:
<br />eeacer
<br />APPROXIMATE INTERVAL
<br />unlet tt fat!I ;':
<br />• onset to 4leHth
<br />00
<br />onset to death
<br />18. WAS MED),zAl.:E:XAMfNEIE
<br />OR CORONERCONTACTED?"
<br />Q YES 511 NO
<br />21c. WAS AN AUTOPE PERFORMED?:•.
<br />0 YES ®NQ
<br />21d. WERE AUTOPSY Mar AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 'NO
<br />22c. PLACE OF INJ#)RY-Athome, farm, street, factory, office building, construction site, ems'(
<br />22e DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION C - iliAlf Y': STREET & NUMBER, APT.NO.
<br />00'60:A..64040., Day, Yr.)
<br />March 8, 2011
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Ma'r>rh
<br />:14'4011
<br />2
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />07:45 PM
<br />e thu best dr my tu)owledge,. death occurred at the time, date and place
<br />en6 rite. to the eanio(s) stated. (Signature and Title)
<br />Jane A. McDonald, MD
<br />xb TOBACCO USE QONTRIBUTE TO THE DEATH?
<br />[, VEs . NO PROBABLY L.I` UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />Zip'COXIE
<br />23a `DATE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PIMONOUNCQD DEAD ..
<br />24e, On the basisof examination and/or investigation, In my opinion
<br />thetime :date and place and due to the taunts) stated. (Signature
<br />26a. HAS ORGAN ORTISSUE r • ATION BEEN CONSIDERED?
<br />0 YES e
<br />2T NAME, TITLE AND -ADDRESS OF CERTIFIER (Type or Print
<br />Jane A McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />28a. REGIS
<br />8 SIGNATURE,�`�1,� r/„pR,M 4 - aej�,,�
<br />I�"_ '"RI
<br />ode!
<br />tl
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a is N0 0 Yes
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 14, 2011
<br />1
<br />
|