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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL,,RE -AI.E WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL S7ATI,6H'IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. /� - f It" v DATE OF ISSUANCEte' ,JUN 3 0 2005 200508855 `Ash_= LINCOLN, NEBRASKA HEA STATE OF NEBRASKA -- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AP CERTIFICATE OF DEATH 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo.. Day. Yr.) Paul .._......--------- _. -Durward _ . .. ... _ D ��L-o v e Noyer Male June 9, 2005 4, CITY AND STATE OR TERRITORY, OR POREION COUNTRY OF BIRTH Q On 15a. AGE -Last Birthday 5b. UNDER 1 YEAR 5c, UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) U Driver /Operator ❑ Removal ❑ Other (Specify) (Vre.) MOs. 1 DAYG HOURS I MINS. U Suicide ❑Could net be determined Republic, Kansas 1 78 1 �._._._� 1 INov. 30, 1926 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH y 505-36-9860 HOSPITAL: Q Inpatient QI1 EB: !BI Nursing Home /LTC ❑ Hospice Facility 8b. FACILITY-NAME (If not institution, give street and number) ❑ ER /Outpatient ❑ Decedent's Home St. Francis Skilled Care Center ❑ DOA ❑ Other (Specify) __._,_.... 8o, CITY OR TOWN OF DEATH (Include Zip Code) ad, COUNTY OF DEATH Grand Island 68803 1 Hall 9a. RESIDENCE -STATE 9b. COUNTY 9o. CITY OR TOWN Nebraska Hall Grand Island 9d. STREET AND NUMBER 9e. APT, NO 1 9f. ,ZIP CODE 910 Hancock Place _ 68803 10a. MARITAL STATUS AT TIME OF DEATH Merrled ❑ Never Married -110b. NAME OF SPOUSE (First. Middle, Last, Suffix) If wife, give maiden name. 9g. INSIDE CITY LIMITS 10 YES ❑ NO El Married, U Widowed ❑ Divorced ❑ Unknown Married, but s�^_._._.,. _......... _.. Mary_ H*� . Il e,l 2.11 O. r_s t 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Maiden Surname) ..� -._L. J . De Noyer 23a. DATE OF DEATH (Mo,, Day, Yr.) 13, EVER IN U.S. ARMED FORCES? Give dates of service If yes. M INFORMANT-NAME OR CORONER CONTACTED? (Y es, no, or unk.) No Steven De Noyer 15. METHOD OF DISPOSITION METHOD -._....._..__._......._ a.EMBA MER- SIGNAT R�j�l. 20. IF FEMALE: Q On N i14� - ❑ Cremation ❑ Entombment 16d. CEMETERY, REMATORY OR AAER LOCATION U Driver /Operator ❑ Removal ❑ Other (Specify) Westlawn Memorial Park 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) / ............ 14b. RELATIONSHIP TO DECEDENT 161b. LICENSE NO. 16c. DATE (Mo., Day, Yr. ) 1328 _ June 23, 2005 CITY/TOWN STATE Grand Island Nebraska. 17b. Zip Code 18, PART I. Enter the o rain otevents-- diseeses, Injuries, or compiications•dhat 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 it necessary. I IMMEDIATE CAUSE' onset to death I IMMEDIATE CAUSE (Final disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF: I onset to 66ath In death) 1 Sequentially list conditions, if any, leading to the cause listed on line a. Enterthe UNDERLYING CAUSE (disease or Injury that Initiated the events resulting In death) LAST (b) DUE TO. OR As A CONSEQUENCE OF: (c) DUE TO, OR AS A CONSEQUENCE OFD (d) I I I onsetto death I 1 onsettodenlh I 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Condlllons contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER 22d.INJURYATWORK? 22e.DESCRISE HOW INJURY OCCURRED ❑ YES La NO 221, LOCATION OF INJURY, STREET R NUMBER, APT. NO, CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo,, Day, Yr.) C 24a, DATE SIGNED (Mo.. Day, Yr.) OR CORONER CONTACTED? ¢ June 9, 2005 Puz ❑ YES J NO 20. IF FEMALE: 21a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? ❑ Not pregnant within past year 1�Gatural ❑ Homicide � U Driver /Operator U YES �'NO El Pregnant at time of death U Accldent❑ Pending Investigation ❑ Passenger / C1 Not pregnant, but pregnant within 42 days of death U Suicide ❑Could net be determined ❑ Pedestrian ltd. WERE AUTOPSY FINDINGS AVAILABLE TO • Not pregnant, but pregnant 43 days In 1 year before death and due to the c h e(s) stated. (Slgna re and Title I ♦ ❑ Other (Specify) COMPLETE CAUSE OF DEATH? • Unknown it pregnant within the past year - ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m '22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d.INJURYATWORK? 22e.DESCRISE HOW INJURY OCCURRED ❑ YES La NO 221, LOCATION OF INJURY, STREET R NUMBER, APT. NO, CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo,, Day, Yr.) C 24a, DATE SIGNED (Mo.. Day, Yr.) 241b. TIME OF DEATH ¢ June 9, 2005 Puz m V) 23b.0ATE ION b (Mo., Day. _._.- 23c.TIMEOFDEATH N _ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 12:35 m E�a� m rno S 23d. To the st of my 1inowledge, death occurred at the time, date and place ut 24a. On the basis of examinalion and /or Investigation, In my opinion death occurred at to c and due to the c h e(s) stated. (Slgna re and Title I ♦ ¢ U the time, date and place and due to the cause(s) stated. (Signature and Title ) T to - 10 25. DIbTUBACCO TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? El YES �NO C1 U UNKNOWN 11DARLY Cl YES [JO - -- Not Applicable if 26a Is NO ❑ YES ❑ NO _..O._ -- - --- '- -- 2T NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Gordon Hrnicek 729,N. Custer Ave. Grand Island Nebraska 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo,, Day, Yr.) ...04* A'. (10� JUN 2 7 2005