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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEC4Y01SIrWH1CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />MAR Q 005 ANLEF COOPER STATE REGISTRAR
<br />LINCOLN, NEBRASKA 20050429 2 HEALTH AND HUMAN SERVICES
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORt
<br />_.._.. CERTIFICATE OF DEATH
<br />05 0,2119
<br />1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX 3, DATE OF DEATH (Mo., Day, Yr.)
<br />Lucile Verlea King Female February 20, 2005
<br />4. CITY
<br />CO1nR TERRITORY,
<br />11 ]e}J7ragka FOREIGN COUNTRY DFBIRTH 5rII(� 56�UOSDERDAY5R HOURS UNDER IMINS. 6. DATE OF BIRTH Day, Yr.)
<br />13, 1915
<br />7. SOCIAL SECURITY NUMBER
<br />507 -05 -7412
<br />8b. FACILITY -NAME (II not institution, give street and number)
<br />Tiffany Square Care Center
<br />8c, CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HO PPI AL.' CI Inpatient QTHER: % Nursing Home /LTC Q Hospice Facility
<br />Q ER /Outpatient ❑ Decedent's Home
<br />❑ DOA El mar
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d, STREET AND UMBER 9e. APT. NO I 9f. ZIP CODE 9g. INSIOE CITY LIMITS
<br />212 S. Oak St. 68801 1 1) YES ❑ No
<br />10a, MARITAL STATUS AT TIME OF DEATH []Married GI Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />- Irvin King - � Mina Livengood
<br />13, EVER IN U.S. ARMED FORCES? Give dates of service If yes. 14a. INFORMANT -NAME 14b. RELATIONSHIP TO DECEDENT
<br />(Yes, no, orunk.) No Irma King Sister
<br />15, METHOD OF DISPOSITION 16a. EMBAL F�SIGNATURE FlftLICE�SE NO. 160, DATE (Mo.. Day, Yr. )
<br />CBUrlal L.1Donation February 24, 200
<br />El Cremation ❑Entombment 16d.CEMETERY REMATORYOROTHERLOCATION CITY /TOWN STATE
<br />URemoval ❑ Other (Specify) Westlawn Memorial Park Cemetery, Grand Island, NE
<br />na FUNERAL City 17b Zip Code
<br />Second, Grand Island, NF T 68801
<br />18. PART I. Enter the chain of oyentq-- disaases, injuries, or complications that directly caused the death. DO NOT enter terminal events such as Cardiac arrest, APPROXIMATE INTERVAL
<br />I
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. I
<br />IMMEDIATE CAUSE: I onset to death
<br />IMMEDIATE CAUSE (Final (a)
<br />disease or condition resulting pUETO,pRASACON5E0UEN EO 1 onset to death
<br />In death)
<br />I I
<br />Sequentially list conditions, ll (b) 1� l A'� - - vL 0..lr�
<br />any, to the cause listed - --
<br />Y 9 DUE T0, OR AS A COIN E+ UENCE OF: �. -' wC ✓�yVl1=r,,, = �- ; U!s� LL offset to death
<br />anllnea. 1 � 1
<br />Enterthe UNDERLYING CAUSE --yy
<br />(disease or Injury that Initiated l�) 1 4,I 1 G-
<br />__ `�` -..
<br />the events resulting lndeath) DUE TO, OR (SA O E uENC _ \ 1 onset to death
<br />LAST
<br />.OTHER SIGNIFICANT CONDITIONS- Condlllons contributing to the death but t resulting in the underlying cause. given in PART I. 19.1 WAS ME X ` ER
<br />(d)
<br />18. PART II MEDICAL EX NER
<br />OR CORONER CONTACTED?
<br />7
<br />YES NO
<br />9
<br />S
<br />20, IF FEMALE. 21a ;NNEROFDEATH 21 b. IF TRANS PORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />❑ ❑
<br />$.
<br />Natural Homicide Driver /Operator
<br />Not pregnant within past year El YES NO
<br />❑ Passenger
<br />❑ Pregnant at time of death ❑ Accident❑ Pending Investigation
<br />9
<br />"r` ���''
<br />❑ Pedestrian --
<br />El Not pregnant, but pregnant within 42 days of death 21 d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />❑Suicide ❑ Could not be determined
<br />❑ Other (Specify)
<br />L l Not pregnant, but pregnant 43 days to 1 year before death COMPLETE CAUSE OF DEATH?
<br />'
<br />C.1 Unknown it re nant
<br />pregnant within the past year ❑ YES NO
<br />1�
<br />..__.. .............
<br />171
<br />22a. DATE OF INJURY_-
<br />(Mo,, Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -Al home, farm, street, factory, office building, construction site, etc. (Specify)
<br />-- Im
<br />22d.INJURYATWORK? 22a DESCRIBE HOW INJURY OCCURRED
<br />❑ ❑ YES NO
<br />t
<br />221. LOCATION OF INJURY- STREET & NUMBER, APT. N0, CITY/TOWN STATE ZIP CODE
<br />23a, DATE OF DEATH (Mo., Day, Yr.) z 24a. DATE SIGNED (Mo., bay, Yr,) 24b.TIME OF DEATH
<br />PS February 20, 2005 ��= m
<br />vx .._... _
<br />N N
<br />23b, DATE SIGNED (Mo . Day ,Yr) 23c.TIMEOFDEATH 8'>� 24c.PRONOUNCEDDEAD(Mo.,Day,Yr.) 24d. TIME PRONOUNCED DEAD
<br />aa� February 22, 2005 8:45Am TL
<br />x En z m
<br />O
<br />o 23d. To the best of my knowledge, death occurred at the lime, date and place 8 w 24e. On the basis of examination and /or Investigation, in my opinion death occurred at
<br />F and due to the cause(s) stated. //•(Signature and Title) ♦ moo the time, date and place and due to the cause(s) stated, (Signature and Title )
<br />cc
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />❑ YES �X NO ❑ PROBABLY ❑UNKNOWN. ❑ YES 0 Not Applicable If 26a is NO ❑ YES Q NO
<br />r'
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER ( PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Pr;nt)
<br />William J. Landis M.D. 2444 W. Faidley Ave., Grand Island, NE. 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />281b. DATE FILED BY REGISTRAR (Mo., Day, Yr,)
<br />I
<br />FEB 2 8 2005
<br />
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