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WH& THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD 0111.-_ ILE WITH, THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIClaE -CTIOM _WATCH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE N' r -- 3/1/2005 200502644 - L9>< .COOPEA_. ASSISTAiVTTATF4EGI;5T4AR LINCOLN, NEBRASKA HEAL. THAND NEWN SERVICES'S'Y370w, ` STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEBVTCES EIN�LI WD S �� j `t V V VITAL STATISTICS _ G CERTIFICATE OF DEATH 1, DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3. BATE OF DEATH /Month. pay. VBarJ Earl Laverne Duering Male November 13, 2004 4. CITY AND STATE OF BIRTH t1( not in USA.. name country) 5a. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /MdnM. Day. Year/ Hildreth, Nebraska (Yrs,) 74 5b, MOS DAYS 5c. HOURS MINS. November 23, 1929 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH 26b. DATE OF INJURY (Mo.. Day. Yr) 505 -34- 1464 HOSPITAL: ® Inpatient OTHER: ❑ Nursing Home 8b. FACILITY -Name flfrof,nstint6on, give sheet and number) ❑ ER Outpatient ❑ Residence St. Francis Medical Centex ❑ DOA ❑ Other(Specdv, 8c. CITV, TOWN OR LOCATION OF DEATH 8d, INSIDE CITY LIMITS 8e. COUNTY OF DEATH Grand Island, Nebraska Yes © No ❑ Hall 9a. RESIDENCE STATE 9b. COUNTY 91. CITY. TOWN GF LOCATION 9d. STREET ANU NUMBER (Including Zip Codel 9e. INSIDE CITY LIMITS Nebraska Hall Grand Island 408 E. South St. 68801 Yes ® No ❑ 10 RACE • (e.g., White. Black. American Indian. 11. ANCESTRY (e.g.. Italian. Mexican, German, etc) 12. © MARRIED ❑ WIDOWED 13. NAME OF SPOUSE /!f wife. give maiden name) etc.) (Specify( White ( Spedify) German NEVER MARI DIVORCED Melva Lippstreu 14a. USUAL OCCUPATION /Give kirrdof work done during most 28c. PRONOUNCED DEAD (Ma.. Day, Yr/ 14b. KIND OF BUSINESS INDUSTRY SSSS �, 2 15. EDUCATION (Specify only highest grade completed) Elementary or Secondary f0 -12) College It 4 or 5 -1 of working life, even if retired) M Self - Employed Carpenter 27d. To the beat of my k�"ledry� occurred at lhag7. date and place and due to the Construction I 1 16. FATHER -NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Edward H. Duering I June Glenn 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 30.6 WAS CONSENT GRANTED? 19a. INFORMANT - NAME 1/ ❑ YES � NO (Yes. no. or unk.) (If yes. give war and dates of services) 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) t7ype or Print) Dr. Ryan D Crouch DO 800 ALpha Grand Island,NE 68803 32a. REGISTRAR . No I 32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) Kris Minnick 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP) 4231 Lariat Lane Grand 20. �BALMER - SIGNATURE d LICENSE NO. 22a. FUNERAL HOME -NAME Island, Nebraska 68803 21 a. METHOD OF DISPOSITION 211). DATE 21c. UCMC I tHT UH UHCmA I Urty "Fm" ❑Burial ❑RemovallNov. 15, 2004 IWestlawn Mem. Park Crematory 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Livingston- Sondermann F.H. Cremation ❑Donation 22b. FUNERAL HOME ADDRESS (STREET OR R,F.D. NO_ CITY OR TOWN. STATE, ZIP) 601 North Webb Road Grand Island, Nebraska 68803 Grand island, Nebraska 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (al. (b). AND (c)) Interval between onset and death PART ... DUE TO, OR AS A Ca)NSEOUENCE OP Interval between onset and death I lb) G`n w DUET OR AS A CONSEQI IENCE OF: Interval between onset and death I I fcl I OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WA5 THERE AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART It PREGNANCY IN THE PAST 3 MO EXAMINER OR CORONER? (Ages 10.54) Yes es No Yes No 26a. 26b. DATE OF INJURY (Mo.. Day. Yr) 26c, HOUR OF INJURY Zed. DESCRIBE HOW INJJRY OCCURRED Accident ❑ Undetermined M ❑ Suicide ❑ Pending 26s. INJURY AT WORK 26L oPe �o F IN URY At home , farm. street. factory 269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation Yes ❑ Na ❑ I „ 27a. DATE OF DEATH (Mo.. Day. Yr.) 28a. DATE SIGNED (Mo.. Day. Yr.) 2ab. TIME OF DEATH November 13,2004 a M r 27b. DATE SIGNED (Mo., DdY. YcJ 27c. TIME OF DEATH 28c. PRONOUNCED DEAD (Ma.. Day, Yr/ 21 PRONOUNCED DEAD /Hour) SSSS �, 2 November 15, 200 k 2 .18pm M AE j8 M J: 2 u 27d. To the beat of my k�"ledry� occurred at lhag7. date and place and due to the 21 On the basis of examination and,or investigation, in my opinion death occurred at causelsl stated! .4 the time, date and place and due to iris Causes) stated. X (Signature and Title - � 01(signature and Title _ _ 29. DID TOBACCO USE CONTRIBUTE TO THE EATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.6 WAS CONSENT GRANTED? / \ ❑ YES ❑ NO UNKNOWN 1/ ❑ YES � NO ❑ YES 17T NO YYY------"' 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) t7ype or Print) Dr. Ryan D Crouch DO 800 ALpha Grand Island,NE 68803 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) NOV 16 2004 I