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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HE
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. '
<br />DATE OF ISSUANCE
<br />FEB 2 '0 200?
<br />LINCOLN, NEBRASKA
<br />202400006
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERV
<br />CERTIFICATE OF. DEATH
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Cecil Junior Hiatt.
<br />2. SEX .
<br />Male '
<br />, 31: DATE OF DEATbi (Mo., Day, Yt.)
<br />February 11,,2007`~
<br />dF. 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Atlantic, Iowa
<br />5a. AGE -Lest Birthday
<br />(Yrs.)
<br />78
<br />5b. UNDER 1 YEAR
<br />5c. UNDER? DAY
<br />6. DATE OF piRTtt (Mo., Day, Yrty
<br />July 27, 1926
<br />ATOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />480-20-8311
<br />8a. PLACE OF DEATH
<br />HOSPITAL: XI Inpatient OHM ❑ NursingHcmeNTC .UHOselteFEGlty
<br />U EWOupetient q Decedent Homs
<br />`��
<br />8b. FACILITY -NAME (If. not Institution, give street and number)
<br />St. Francis Medical Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />,Grand Island 68803
<br />8d. COUNTY OF DEATH ' - ~�r
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />Sb. COUNTY
<br />Hall
<br />9c. CITYOR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />4040 Patchwork Place
<br />9e. APT. NO
<br />91. ZIP CODE
<br />'" 68803
<br />9g. INSIDE CITY LIMITS
<br />•
<br />X3 Yi:S, ❑ we
<br />10a. MARITAL STATUS AT TIME OF DEATH (Darned ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />1013. NAME OF SPOUSE (First, Middle, Last, Suffix) It wife, give maiden name.
<br />Junette Anderson
<br />11. FATHER'S -NAME (First, . Middle, Last, Suffix)
<br />Lawrence C. Hiatt
<br />12. MOTHER'S -NAME (FIret, • Middle, Maiden Simeme).
<br />Bessie an,
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service it yes.
<br />(Yes, no,orunk.) No
<br />14a. INFORMANT -NAME
<br />Junette Hiatt
<br />t1St-eeri
<br />14b. RELRT$ONSHIP TO DECEDENT..
<br />Wife ' '
<br />16. METHOD OF DISPOSITION
<br />Muria! ❑Donation
<br />❑ Cremation ❑ Entombment
<br />❑Removal ❑ Other (Specfy)
<br />18a. EMBALMER-SIGNATURE� ,�
<br />O'SGcc+-0/�it.JaZ
<br />16b. LICENSE NO.
<br />'K/3'24'
<br />18c. DATE (Mo.,Dap Yr.1 -F
<br />February lby � /'
<br />16d. CEMETERY, CREMATORY OR OT ER LOCATION CITY / TOWN STATE
<br />Grand Island Cemetery, Grand Island, Nebraska:
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 West Second, Grand Island, NE.
<br />1S. PART I. Enter the chain o - =n v --diseases, Injuries, or complications --that directly caused the death. DO NOT enter terminal events such as cardiac arrest, I APPROX
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one meow a line. Add additional lines If rnecesaary. i
<br />IMMEDIATE CAUSE: , .. ...:.. . _ ' ` . I+ trrileWb
<br />IMMEDIATECAUSE(ring (a)
<br />17b. Zip Code
<br />68801
<br />it
<br />&gib
<br />dlloww rrwrMMonroaumwil DUET , OR AS A CONSEQUENCE OF: I onset to Iegih. -
<br />. In death). I :.•
<br />Sequentially list oondltlone,If (h)
<br />I t
<br />any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: I melte death
<br />on linea
<br />Ent rtheUNDERLYINGCAUSE
<br />(diseaseorin)urythetInitiated (c) .. i
<br />the eventaresuftingindeath) DUE TO, OR AS A CONSEQUENCE OF: Ieneettodeath -"
<br />LAST I . .. _
<br />Id) I'
<br />18. PART it. OTHER SIGNIFICANT CONDITIONS-CondKione contributing to the death but not resulting In the underlying ause given in PART I.
<br />19. WAS MED10A1.e(AMWER v
<br />cR'CORONi$OOINACTEO9
<br />❑ YES ,,'Q NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />21e. MANNER OF DEATH
<br />atural CaHomicide
<br />0 Accident Pending Investigation
<br />❑ Suicide ❑ Could not be determined❑
<br />21b.IFTRANSPORTATION INJURY
<br />O Driver/Operator
<br />ID Passenger
<br />QPedesirlan
<br />Other (Specify)
<br />21digASANAUTO&CPERECI 9
<br />❑YESNO
<br />21d.WERE`AUTOPSYPINDINGGAYAE.ABLETO ;
<br />COMPLETE CAUSE OF DEATH?
<br />❑ YES '❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction she, etc. (Specify)
<br />, 22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />2a. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />7bbe`compteted by ...
<br />Atkendkig PHYSICIAN
<br />ONLY
<br />23a. DATE OF DEATHMo., DpY, Yr.)
<br />til
<br />24e. DATE SIGNED (Mo., Day, Yr.)
<br />246.TIMEOFOa I1
<br />..
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME Pi )NCW'DEAD • '
<br />236. DATE SIO (Mo. Day, Yr.
<br />23c.TI OF DEATH
<br />p
<br />23d. To the b t of my wled ,death occur ed at the time, date and place
<br />and due to the cause(s) t ed. (Signature and Title) y B
<br />ii
<br />24e. Qin the basis of examinant) and/or Irivestl niton, M I$.ro desttrorxv It:
<br />the time, date and plain and due to the cause(s) stated. (S n stare and ?Heli ) y
<br />25. DID TOBACCO USE CONRIBUTETOTH EATH?
<br />❑ YES ANO ❑ PROBABLY 0 UNKNOWN
<br />265 HAS ORGAN OR TISSUE DONATION T ON BEEN -CONSIDERED?
<br />❑ YES JO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable I(2gaisN9 U YES " ❑, NO
<br />27. NAME, TI EA D ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type drPrkd)"
<br />Gordon J. Hrnicek M.D. 729 N. Custom ;Ave., Grand Island, NE. 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />,'. , , (, idr •FEB
<br />28b. DATE RLEDBY REGISTRAR (Mo., D 'YrA '
<br />16 ZOO?
<br />•
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