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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 />RECORDSPiffICE,,,14r0(941S, THE LEGAL DEPOSITORY FOR VITAL RECORPS
<br />202305311
<br />STANLEY S. DOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OFHEA).TW AND HUMAN SERVICES
<br />CERTIFICATE OF DE ►TH:
<br />1. DECEDEt Pfd DAME (First, Mid Ee ,
<br />James Ma vIn Davis
<br />d.:I TT ANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Fairbury, Nebraska'
<br />7. SOCIAL SECURITY NUMBER
<br />507-34-4377
<br />Last, Suffix)
<br />8b. EOM -NAME (If riot Institution, give street and number)
<br />Veterans Affairs Medical Center''
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />. Grand Island 68803
<br />ea. RESIDENCE•STATE
<br />Nebraska ..
<br />W 9d. STREET AND NUMBER
<br />4019 Sacramento Circle
<br />tits. MARITA( 81"ATUS AT TIME OF DEATH I] Married 0 Never Married
<br />Mauled,. bud venerated ❑ Widowed; 0 Divorced 0 Unknown
<br />11. FATHER`S-NAME (First, Middle, Last,Suffix)
<br />Guy Davis
<br />9b. COUNTY
<br />Hall
<br />6a AG@•LastBIrthday
<br />(Yrs )
<br />81
<br />Iib. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Ba PLACE OF DEATH
<br />HOSPITAL rzi Inpatient
<br />0 ER/Outpatlent
<br />E0 DOA
<br />Sc. CI'T'Y OR TOWN.
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />September 17, 2016
<br />B. DATE OF BIR'4'if (MO '.Dgy,'f) ,
<br />November 18.1934'
<br />OTHER :❑ Nursing HomeILTC
<br />ID Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />1Db. NAME OF SPOUSE (First ,.:Middle, Last,
<br />Joan Mare BDIey
<br />14a. INFORMANT -NAME
<br />Joan Marr Davis
<br />12 MOTHER'S -NAME (First,
<br />Beulah Kirby
<br />3 EVER IN U.S,:ARMED:FORCES? Give dates of service if Yes.
<br />IY NQr m Unk-) 'es .A2/24/1954-01/10/1956
<br />18 METHOD OF DFSROSITION 16a. EMBALMER -SIGNATURE
<br />❑ Burfai [I Donation Not Embalmed
<br />GrematIon
<br />Entombment
<br />Other:(Specify)
<br />178`FUNERAL I OME NAME AND MAILING ADDRESS (Street, City or Town, State):
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island: Nebraska'
<br />. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />8b LICENSE NO.
<br />9f. ZIP CODE
<br />68803
<br />Hospice Fattility
<br />9g. INSIDE CrTYUMITS:
<br />ffd YEs ❑ No
<br />Suffix) If wife, give: maiden nit
<br />Middle,
<br />Maiden Surname)
<br />14b. RELATIONSHIP.TO DECEDENT..
<br />Wife
<br />16c. DATE (Mo. Day,. Yr.)
<br />September 20, 2018
<br />CAUSE OF DEATH (See ipl tructbonsend examples)
<br />'t8, PART I Enter.th.4has et Swots- -cuseases, injuries, or complications -Mat directly caused the death. DO NOT enerterminal events such as cardiac arrest,.
<br />nopiratentafrekc orwYdditlla fibrillation without showing the etiology DO NOT ABBREVIAte. Enter only One rause Oil a linik Add additional lines if. necessary.
<br />IMMEDIATE CAUSE:
<br />a) Anaplastic Astrocytoma, Grade 3
<br />IMMEDIATE CAUSB (F'ii al
<br />,aEabSe.., oW,,.'itiwa`e6'r',y
<br />In death)
<br />serryetltiany hnt amtitlmona.If
<br />any .Ngana teele:cause gated:::
<br />on gne`e
<br />Enter the U NDERLYINO CAUSE
<br />(tlkeaaeorlNuf tutiniktett,
<br />the events resulting: In dead
<br />LAST;?
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />61
<br />APPROXIMATE INTERVAI;
<br />onset to dB$h
<br />3 months
<br />onset t ttaert
<br />TO, 0 S CONSEQUENCE OF:
<br />onsetlo
<br />ER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />IF FEMALE.
<br />❑ NetpreanantadMinpaetyear
<br />❑ FrOnthathanle of death
<br />❑ Not Plegnani'. rut pregnam within 42 days Of
<br />❑ Not preSitant. but pregnant'42 days to 1 year'
<br />❑. i#.dknGwn if prsgrualt wadi l the past year
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />v
<br />3
<br />22d. INJURY A'1+;SIVORI4?r ..
<br />]YES ONO
<br />h
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide 0 could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />Dri erlOperator
<br />0 Passenger
<br />0 Pedestrian
<br />Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES
<br />21c. WAS AN AUTOPSYPERYlED3f
<br />❑ YES 1/)
<br />21d. WERE AUTOPY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF D4ATN4 `
<br />❑ YES ❑: NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction sem, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />INJURY • STREET es NUMBER, APT.NO.
<br />(DEATH (Mo., Day, Yr.)
<br />Se;,eirber 17.2016
<br />23b. GATE SI a( 0 (Mo., Day, Yr.)
<br />e =m:er I _ e 16
<br />CITY/TOWN
<br />To the best of my knowledge, death occurred at the time, date and place
<br />and due to the causes) std. (Signature and Tab)
<br />Catherine M. Eberle, MO:
<br />2$ 0(0 +BACGI;TUsi ` l'uTRIsureftO,THE'DEATH?
<br />❑ YES NO 0 PROBABLY © UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Catherine M. Eberle, MD, 4101 Woolworth Avenue, Omaha, Nebraska, 68105
<br />STATE
<br />24a. DATE SIGNED (Mo„ Day, Yr.)
<br />A'5
<br />g24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />J
<br />24e. On the basis of examination andlor investigation. to my opinion death occurred at
<br />the time, date and place and due to the causes) elated. (Signeltoth and Title)
<br />24b. TIME OF DEATH
<br />ZIP CODE
<br />24d. TIME PRONOUNCED DEAD
<br />26a. HAS ORGAe OR TI SUE DONATION
<br />❑ YES l NO
<br />CONSIDERED?
<br />28b. WAS CONSENT GRANT
<br />Not Applicable If 28a Is NO
<br />28a, REGISTRAR'S SIGNATURE
<br />❑Q
<br />28b. DATE FILED BY REGISTRARDay,Yr )
<br />September 20, 2016
<br />
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