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<br />_. _.._ _STATE OF, NEBRASKA
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<br />WHEN THIS COdyv CARRIES THE RAISED SEAL OF STATE OF:NEBRASKA. ITCERTIF!ES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAsick DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATEOF ISSUAN
<br />2/1312123
<br />LINCOLN, NEBRASKA
<br />202$0081
<br />3g4ttil gad4.441
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />TATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />r+rth..•n •1. DECEDEx-re f1Aelg (ER'st
<br />Marianne':; Milson
<br />4. CITY' AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Middle,': Last, Suffix)
<br />Vallev,COUnty, Nebraska
<br />UMBER
<br />T. SOCIALSECURITYN
<br />508-542578
<br />8b. FACILITY -NAME (If hot Institution, give street and number)
<br />Good Samaritan Society -Wood River
<br />1
<br />sc, C1TY OR T .NOF DEATH (Include Zip Code)
<br />Wood River 68883.
<br />9a RESIDENCE -STATE
<br />Nebraska J.
<br />9b. COUNTY
<br />Hall
<br />5a; AGE - Last Birthday`
<br />(Yrs.)
<br />72
<br />5b UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a, PLACE OF DEATH
<br />HOSE PITAL ] Inpatient
<br />Q ER/Ou patient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />3. DATE OP DEATtt (Mti., Day Yt,;):.
<br />October1'5, !IVg
<br />6. DATE OF BIRTH (Ma, bay Yr.)
<br />May 28,`4:84
<br />OTHER ®NursingHome/LTC`
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />9c. CITY OR TOWN
<br />Wood River
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9d..STREETANDNUMBER
<br />4+101 East Street
<br />""Il.AL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First,
<br />Hal Francis Wilson
<br />9e. APT. NO.
<br />#Device Poesy
<br />9f. ZIP CODE
<br />68883
<br />Middle,Last, Suffix) If wife, give
<br />1. FATHER S -NAME (First, Middle,
<br />Leonard :: -Resnik
<br />Last,
<br />Suffix)
<br />tints:
<br />12 #OTHER'S -NAME (First, Middle, Malden Surname).
<br />Edna Srnolik -
<br />r 13. EVER IN U.S. ARMED'FORCES? Give dates of service If Yes.
<br />Eg (Yes, No. or Unk.) No
<br />aa. METHOD QF.DISPOereoN
<br />0,804 ❑ Don#Uon
<br />litl"PreinrietiriLleritarribment
<br />❑`Removal" ❑ Other (Specify)
<br />14a. INFORMANT -NAME
<br />Hal Francis Wilson
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />14b. RELATIONSHIP TO DECEDENT::'
<br />Spouse
<br />1ac.DATE;(88o,DaK Yr)
<br />October:17 2t 1S .
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />11a FUNERAL PIOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Alf Faiths funeral Home, 2928 S: Locust Street, Grand Island, Nebraska
<br />$TATE
<br />Nebraska
<br />CAUSE OF DEATH (See Instructions and examples)
<br />11. PART I. Enter the chainof awente.'diseases, injuries, or complications -that directly caused the death. DO. NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventticuiar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Iihes If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATECAUSE(Finat 8) Progressive'. Dementia
<br />disadae dr concision reetddnp
<br />0
<br />in death) DUE TO, OR A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to the caul listed
<br />on line a
<br />Ent;r14 U NDER VI 40 GAUBE
<br />(diseaseOr 'Muni -that inldeted
<br />the events resulting In death)
<br />LAST •
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PARTI% OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART L
<br />Seizure Dis©rder
<br />b If:FEMALfi: <„
<br />Not pragnantyatltln
<br />'EpPregnamt atffine oE4aath
<br />❑'Not pregnatji' but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before: death
<br />Lhhknewn if 1#aanant wibh1 the past year
<br />22a.OATE OF N,IURY (Mi):; Day, Yr.)
<br />22d. INJURY AT WORK?
<br />0 YES D No....::::..
<br />21a. MANNER Of DEATH
<br />® Natural Homlttde.
<br />0 Accident ❑ Pwtd:Ing Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />210,1F TRANSPORTATION INJURY
<br />Dow/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />Other (Specify)
<br />16.4VAS naso i eve NER
<br />OR CORO$ER.CONTAttlittil
<br />NO
<br />21 C. WAS ANA IPSP PERFORMED?
<br />❑YE.
<br />21d. WERE AUTOPSY huorticas AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES Q NO
<br />22c. PLACE: OF INJURY At hone ::farm, street, factory, office building, construction site, et4. (SpeciI#I
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f.:LOCATION 'OF INJURY: STREET &NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 15, 2015
<br />cITYrTOWN'
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Otkober 16: 2015 . 07:08 PM
<br />80 i o Iha best 0f M l knowledge;; death occurred at the time, date and piece
<br />Mils due 10 818 4 atief a)lstatod (Signature and TWO
<br />Jane A. McDonald. MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. Gil the basis of examination and/or investige ton, in my opini
<br />Lha time, date and place and due to the cause(s) stated. (Sig
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES 10 NO
<br />26. DID TOBACCO USE orratiBUTE TO THE DEATH?
<br />❑YES :i(3(] NQ Q PROBABLY ❑ UNKNOWN
<br />27. NNME, Y)TI E ANDADDRESS OF CERTIFIER (Type or Print
<br />Jane A. MPDonatd, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />28a REGISTRAR381GNATURE��` S.
<br />d4ARI gleamed
<br />to and t' tre)
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO ❑ YES Q
<br />NO
<br />28b. DATE FILED BYREGISTRAR (Mo., Day, Yr.)
<br />-October 19,2015
<br />ca
<br />N
<br />N
<br />CID
<br />
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