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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERV ICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIG -EPEC RQ ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL3tATISn&C _ EC?T€2N, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE APR p05 - - - - T.4NLrift.`�OOPER LINCOLN, NEBRASKA 200503997 = HEAL HAND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE -AND SUPPORT CERTIFICATE OF DEATH .__.7 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo,, Day, Yr.) 'Rosemarie NMI. McElroy _ Female April 5, 2005 r_ _ ��. 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.) f, (Yrs.) 76 MOS. DAYS HOURS MINS. February 9, 1829 b Hastings, Nebraska 7 SOCIAL SECURITY NUMBER - Ba. PLACE OF DEATH 1 506-28-7335 - HQSPITeL: ❑ Inpauem 4IHEB:7 NursingHome /LTC ❑ Hospice Facility 8b. FACILITY -NAME (It not institution, give stroel and number) CLi ER /Outpatient C3 Decedent's Home St. Francis Skilled Care �r! ❑ iDCA ❑ Other(Specify) " 8c, CITY OR TOWN OF DEATH (Include Zip Cade) 8d. COUNTY OF DEATH 3 Grand Island 68803 Hall 9a. RESIDENCE•STATE 9b, COUNTY 9c. CITY OR TOWN Nebraska Hall Grand Island 9d. STREET AND NUMBER 9e. APT. N791. IPCOtlE 3136 Laramie Drive 8803 10a. MARITAL STATUS AT TIME OF DEATH QtMarried ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. U Married, but separated ❑Widowed ❑Divorced ❑Unknown James L. McElroy 9g, INSIDE CITY LIMITS V YES ❑ NO 11. FATHER'S -NAME (First, Harold Middle, Last, Suffix) F. Bates 12. MOTHER'S•NAME (First, Lyl.a Middle, Maiden Surname) J. Harkins 13, EVER IN U.S. ARMED FORCES? Give dates of service it yes. 14a. INFORMANT -NAME APPROXIMATE INTERVAL I respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. 14b. RELATIONSHIP TO DECEDENT No I onsettodeath I Jams L. McElroy IMMEDIATE CAUSE (Einar Husband (Yes,no,orunk.) 15. METHOD OF DISPOSITION I onset todeath In death) April 5r2005 1:15 pm i8b. LICENSE NO. L. - 16c. DATE (Mo., Day, Yr. ) tae. EMBALMER - SIGNATURE on line a. Not Embalmed Enter the UNDERLYING CAUSE April 2005 ❑Burial ❑Donation O f ^� .6, (Cremation 11 Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE Central Nebraska Cremation Service Gibbon, Nebraska ❑Removal ❑ Other (Speolly) 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Ty , eorPrint) 17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Coda Apfel Funeral Home 1123 West Second, Grand Island NE i 68801 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN 18. PART I. Enter the chiuct QLeven1E••diseases, injuries, or complications- -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL I respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. 23a. DATE OF DEATH (Mo.. Day, Yr.) IMMEDIATE CAUSE: I onsettodeath I w 9� p 5; 200 � IMMEDIATE CAUSE (Einar disease or condition resulting 9 DUE. TO, OR AS A CONSEQUENCE OF: I onset todeath In death) April 5r2005 1:15 pm Sequentially list conditions, If (b) L. any, leading to the cause listed EWE TO, OR AS A CONSEQUENCE F' onsettodeath on line a. w gr Enter the UNDERLYING CAUSE (disease or Injury that Initiated (c) and due to the (s) stated. (Signature and ) ♦ the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onsettodeath LAST I I 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause ' n in PART I. 19, WAS MEDICAL EXAMINER ! ' �✓ OQ R CORONER CONTACTED? ACTED? °yC .! YES UY_N/ NO 20. IF FEMALE: 212.MA NEROFDEATH 21b. IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? Natural ❑Homiclde ❑Driver /Operator �/ 101 pregnant within past year U YES d,d NO Passenger ❑ Pregnant at time of death U Accident❑ Pending Investigation _ ..... C3 Not pregnant, but pregnant within 42 days of death Ll Suicide El Could not be determined G Pedestrian 21 d. WERE AUTOPSY FINDINGS AVAILABLE TO L] Not pregnant, but pregnant 43 days to 1 year before death LJ Other (Specify) COMPLETE CAUSE OF DEATH? �� * Unknown if pregnant within the past year _ ❑ YES R N0 22a. DATE OF INJURY (Mo., Day, Yr,) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) ..� _....... m ....- 22d.INJURY AT WORK? 22e, DESCRIBE HOW INJURY OCCURRED LJ YES ❑ NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo.. Day, Yr.) 24a. DA. E SIGNED (Mo., Day, Yr.) 24b.TIME OF DEATH w 9� p 5; 200 ¢ w k m m ( Da Yr. 23c.TIME OF DEATH 23b. DATE SIGNED Mo., y ) �^ x >, 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD April 5r2005 1:15 pm EHa= m i $ mo a 23d.To the best of my kne ledge, death occurred at the time, date and place Title w gr 24e. On the basis of examination and/or Investigation, In my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) • c o d and due to the (s) stated. (Signature and ) ♦ Cr M lL U O f ^� U o 25.DIDTO ACC SE ONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? J YES N0� ❑PROBABLY ❑UNKNOWN ❑YES UYNO Not Applicable 1126a is NO d YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Ty , eorPrint) Jane McDonald M.D. 800 N. Alpha Ave., Grand Island, NE 68803 SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) 28a, REGISTRAR'S ,( APR 12 2005