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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMANSERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINJg.!!EC~.QNFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST4~TlC$,,$E(lIlfJ/fft~HICH IS
<br />
<br />:::;::~~;~::;TORY FOR VITAL RECORDS. ~._.-C.'.=~:. ~~:":c~':Z:1-f~.-~?~~~
<br />AUG 1 7.2005 fK)"!'~7tjANLEYS:igg~ER
<br />2 0 0 5 1 0 4 0 7 ~'ASS!stANT-STATE'R';(;JsJfflAR
<br />LINCOLN, NEBRASKA ~EALt-!lAND HUAfAftf=sEFWICES
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<br />.', :
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<br />.-. '~ .~-'...,---.
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANtEAt-lD s0.pp,gR~n 5
<br />__ CERTIFICATE OF DEATH . ... .
<br />
<br />08937
<br />
<br />~
<br />
<br />Hazard, Nebraska
<br />
<br />5., AG~.L..t Birthday
<br />(y",) 7 7
<br />
<br />5b. UND~R 1 Y~AR
<br />MOS. DAYS
<br />
<br />Sc, UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />3. DATE OF D~ATH (Mo" D.y, Yr,)
<br />Augtl8.t. 8, 2005
<br />
<br />6. DAT~ OF BIRTH (Mo., Day, Yr.)
<br />
<br />I. DECEDENT'S.NAME (FlrSI,
<br />Charles
<br />
<br />Middls, L.st,
<br />William de la Motte
<br />
<br />SUlfix)
<br />
<br />2, SEX
<br />Male
<br />
<br />4, ciTY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />November 25,1927
<br />
<br />7. SOCIAL SECURITY NUMBeR
<br />505-36-9120
<br />
<br />ea. PLACE OF DEATH
<br />
<br />1iO..S.ElIAl.:
<br />
<br />o Inp.tient
<br />
<br />QJJ:tI;IJ: 00 Nursing Home/LTC W Ho.pica facility
<br />
<br />Rh. FACILITY. NAME (If not Institotlon, give .treet and nomber)
<br />
<br />Tiffany Square Care Center
<br />
<br />o ER/Ootpattant
<br />
<br />o Decedent's Home
<br />
<br />_Gra_nd Island
<br />9.. RESIDENCE. STATE
<br />Nebraska
<br />
<br />68803
<br />
<br />.. '---1~:~~~~
<br />
<br />o CO\ 0 Olher (Specily)
<br />
<br />.._._w --'18dCOU~T:0~~ATH .
<br />J 9C..G. ";:~II Is 1 a n d.l-- __._'
<br />
<br />9a. APT. NO 9t, ZIP cODE
<br />68801
<br />no " "" ".
<br />lOb. NAME OF SPOUSE (First, Middle, La't, Sulllx) II wife, give maiden nam..
<br />Dorothy Fischer
<br />
<br />9g, INSIDE ciTY LIMITS
<br />00 YES 0 NO
<br />
<br />8e, CITY OR TOWN OF DEATH (Incloda Zip Code)
<br />
<br />9d. STREET AND NUMBER
<br />623 E. Meves Ave.
<br />
<br />lOa, MARITAL STATUS AT TIME OF DEATH ~Marrled U Never Married
<br />
<br />o Married, but ,ep.raled Ll Widowed 0 Divorced W Unknown
<br />
<br />11, FATHER'S-Nr~ w(;~:n-~~Idd~- d e La~'a Mo ~~~~MOTHER'S'NA~~ :;SI,"
<br />
<br />13. EVER IN U,S, ARM~D FORCES? Give deles ol.ervloell ya.. 14a.INFORMANT.NAME
<br />(X~~ or unk) 3/ 26 /19 4 6 - 4 / 2 3 / 47 Do rot h y de
<br />
<br />Middle, M.lden Sorname)
<br />Beethe
<br />
<br />o cremation 0 Entombmenl
<br />
<br />16a: EM ALMER'SIGNATU~i'" _
<br />
<br />( rM(llJ;hA,'~J.J3c'_._____
<br />16d~ CEMEl1~, CREMATORY OR(el-HER LOCATION
<br />
<br />1a Motte
<br />
<br />'l~_~C;N~E NO,
<br />
<br />CITY {TOWN
<br />
<br />14b. RELATIONSI11P TO DECEDENT
<br />wife
<br />
<br />o Donation
<br />
<br />16c, DATE (Mo., Day, Yr.)
<br />
<br />Au ust___ 12" 2005
<br />STAT~
<br />
<br />o Removal o Other (Specily) Grand Island City Cemetery
<br />
<br />Grand Island, Nebraska
<br />
<br />:, ~ ".
<br />
<br />
<br />
<br />17b, Zip cod.
<br />68801
<br />
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Slteet, City or Town, Statal
<br />Faiths Funeral Home,2929 S. Locust St.,Grand Island,
<br />
<br />rART l. Enler the chain 01 events--diseases, injuries, or complicalions--thal directly caused the deaHl. DO NOT enter terminal events suoh as cardiac,arrest,
<br />respiratory arrest, or ventrIcular fibrillation wHhout showIng the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additIonal lines if necessary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />Sequentially 11.1 condition., If
<br />BnYt leading to the cause llstl:!d
<br />on line 8.
<br />Enler Ih. UNDERLYING CAUSE
<br />(dl.ea.e or Inlory Ihal Inltleled
<br />the events resulting In death)
<br />lA'1f
<br />
<br />IMMEDIATE CAUSE \
<br />
<br />(a) ~_E:~_::\C
<br />DU~ TO, OR AS A CONSWU~NCE,OF:
<br />
<br />(b) I 5 ~~<...
<br />_.n _..
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />~
<br />l~~"'
<br />
<br />onsB,t.'o death t\.
<br />
<br />?:, -y\..-'~~
<br />
<br />IMMEDIATE CAUSE (Flnel
<br />dl$l:!i!lS8 or condition re9ulUng
<br />In deelh)
<br />
<br />I onset to death
<br />
<br />0~--.JL,
<br />
<br />I ~'A>Vj
<br />
<br />--: onsettodeeth.1
<br />I
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on..t to d..lh
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS.conditlons contributing 10 Ihe de.lh bul not re.ultlng In the onderlylng c.use given In PART I.
<br />
<br />
<br />~~"J~ ,\..-~'-~..,..:v I ________.
<br />20. IF FEMALE: 21., MANNE 0 EArH 21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Not pregnant wllhln p..' year ~'Iur Homicide 0 Driver/Operator
<br />o Pregnant at time of death 0 AccldantO Pending Inv..tlg.llon 0 P....nger
<br />W Not pregnant, but pregn.nt within 42' day' 01 deeth 0 Solcld. 0 Could not be d.t.rmln.d 0 Pede.trlan 21d. WERE AUTOPSY FINDINGS AVAILABL~ TO
<br />o Not pregn.nt, but pregnent 43 d.y. to 1 yaar balore death U Other (Spaclly) COMPLETE CAUSE OF DEATH?
<br />o Unknown if pregnant within Ihe p"1 year 0 YES U NO
<br />. 22~, DATE OF INJUR~iM;~D~:_2b:TllAE OF j:JUR~]' ;... PLACE O~'N~URY'At homo, I.rm~ slree;, I.ctory, oftlce buIlOln~, con.tructi~~ ~ite, elc, (SP~i~)
<br />
<br />
<br />22d.INJURY AT WORK? 22.. DESCRIBE HOW INJURY OCCURRED
<br />
<br />
<br />19, WAS M~DICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />DYES !!l NO
<br />
<br />DYES
<br />
<br />jl NO
<br />
<br />DYES 0 NO
<br />
<br />221. LOCATION OF INJURY - STREET & NUMB~R, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STArE
<br />
<br />ZIP CODE
<br />
<br />24a. DATE SIGNED (Mo., D.y, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />23c, TIME OF DEATH
<br />3:42P.m
<br />
<br />z>
<br />~~~
<br />_II:
<br />~Ul~
<br />c.l-=r::i
<br />E ."j';~
<br />8ffiz
<br />llz=>
<br />~~8
<br />8~
<br />
<br />m
<br />
<br />24C. PRONOUNC~D DEAD (Mo., Day, Yr.)
<br />
<br />24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d, To tha best 0 my kno edge, death occorred.t Ihe time, dete .nd place
<br />and do.lo theCaU"e(s~~, (Slgnatura and Title)" >J.. A A
<br />
<br />G-,,) c I~~..!)
<br />
<br />25. DID TOBACCO USE CONTRIBUTETOTHE DEATH? 26a, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONS~NT GRANTED?
<br />
<br />W YES 0 NO 0 PROBABLY 0 UNKNOWN 0 YES \.'''0 Not Applicable II 26. I. NO 0 YES W NO
<br />~TLEA'NDADDAESSOF'CERTIFIER (PHYSiCiAN','CORONERISPHYSlciAN~6RNEY) (Type or Prlnt)- .. ... ... . , - --..--
<br />William J. Landis, M.D.,2444 W. Faidley Ave.,Grand Island, NE 68803
<br />
<br />248. On the basIs olexamlnallon and/or invesllgallon, in my opinIon death occurred at
<br />the lime, date and plac. and due to the cao.e(.) Slaled, (Slgnatora and TltI.) "
<br />
<br />28a, REGISTRAR'S SIGNATURE
<br />
<br />
<br />2Bb. DATE FIL~D BY REGISTRAR (Mo., Day, Yr,)
<br />AUG 15 2005
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