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202505859
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Last modified
10/20/2025 4:19:31 PM
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10/20/2025 4:19:30 PM
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202505859
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STATE OF NEBRASKA <br />.�i5'JJJ+;c.�•.'....,%!6GI'II:I;IN.IIQI��•,.:...�••Y••�P/d0.��...,.`�<:14f1a'I;I,NiN35•:>......•attL4�t,l�� <br />W l ltit,;;.THIS ' OO t CARRIES THE RAISED. SEAL OF. THE _"STATE OF NEBRASKA, <br />CEltt# fI S ,THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL REC <br />ON .FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, <br />QROS;:OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF.1S'..�...ANCE <br />20 202505859 SARAH14-11 <br />LI COL(lr:.N . <br />:breaks <br />SOCIAL SECURIT' <br />550$732.8385 <br />!� REb.AENCE-STA1'E <br />ebraska <br />d . Tif T.AND NUMBER <br />- ,647-Mea t dbI. p.Cive <br />1MTei: MARITAL.S'iATtiS AT TIME OF <br />ASSISTANT STATE REGIS"I ilvA <br />DEPARTMENT OF HEALTH <br />AND HUMAN SERVICES; <br />STATE OF'NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES <br />CERTIFICATE OF DEATH <br />N COUNTRY OF BIRTH <br />glum street and number) <br />ttr me <br />fib. COUNTY <br />Hall <br />TH'] '] ]Married 0 Navel' Married <br />butsepsntsd ErWitio Q Divorced 0 Unknown <br />EAYlhE.R'S-NA E .'(First, Middle, Lasts: <br />Walter_ .:Dobbs . <br />13.-EVERiN Li, S:,i4RMED=FORCES? Give <br />ries. No or t(nk Yeti; , b1/tom t95 <br />datse of service If Yes. <br />3»10/20/1954 <br />Si, Aga - Listal <br />(Yrs.) <br />91 <br />.5b. U'NOER 1 YEAR <br />2.SEX <br />Male <br />Sc. UNDER 1 DAY <br />PLACE OF..`DEATH' <br />IQf1inTALti Itipietfei# o' <br />Q ER/Outpatient <br />Q DOA <br />I8d. COUNTY OF DEATH <br />Buffalo <br />9e. CITY OR TOWN <br />Grand Island <br />ltltr. NAME OF' SPOUSE (First, Middle, <br />Jaceel Kay Smith <br />14a. INFORM4ANT•NAN E' <br />Jaceel Kay Dubbs <br />tbd. CEMETERY, CREMATORY OR OTHER LOCATION <br />Central Nebraska Cremation Services <br />1i7I, FUNERAL:HOME NAME AND.MAIL1NG ADDRESS (Street, City or Town: State) <br />"• Alt:Faiths.F eerat•Home, 2929 S. Locust Street, Grand Island, Neb <br />• <br />Rod <br />W. ZIP CODE <br />68801 <br />12. MOTHEft`SNARE (First, Middle, <br />Lucy Dillon <br />CITY I TOWN <br />Gibbon <br />CAUSE OF DEATH (See inetruot)b lsand ex�lfrw(eII) <br />diseases, Injuries, or aompacaaonsshst directly caused the death. DO NOT enter terminal events such as eardMo airaeT, <br />riipr2fsltai# without shook* the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add sddhbnal Sass M mammary. <br />IMAfEDiATE CAUSE: <br />a) Cardiac Arrest <br />DUE TO, OR AS A CONSEQUENCE OF: <br />b) Diagnostic Chronic Heart Failure <br />AS A CONSEQUENCE OF: <br />DUE TO, OR AS A NSEQUENCE OF: <br />s Contributing to the death but not <br />21a. MANNER OF DEATH <br />® Natural Q Hominid* <br />Q Accident 0 Priding WISH <br />Q Suicide Q Could not be determined" <br />22b. TIME OF IN <br />22e. PLACE OF I <br />RY OCCURRED <br />23c. TIME OF DEATH <br />92:30 PM <br />TRIBUTE Tt'THE DEATH? <br />PROBABLY •UNKNOWN <br />`li LE AND AO iREBS 00 C4f4T1FIER (Type or Print <br />'r;t`vdgers;,MD, 4510 E,56th St, Kearney, Nebraska, 68847 <br />stilit#dying cause given In PART I. <br />21b. IF TRANSPORTATION INJURY' <br />.Q. DtiverlOperetor <br />QPusenger <br />QPedes:rise <br />Q Other (Specify) <br />STATE '• <br />SIGNED (Mo:, Osy, Yr.) <br />PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME <br />. 2Ae. Or tht balls of *nomination eragor hw.etlg tisn in <br />• the tlirme date and place end du• to OM causelei#tetMs <br />26a. HAS ORGAN OR TISSUE. DONA <br />Q YES <br />N BEEN CONSIDERED? <br />28b. DATE FH,E <br />November 0, <br />
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