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<br />~
<br />
<br />STATE OF NEBRASKA
<br />
<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 R~CORD_ONFILF WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSrdJijiiiCijl,-="f1!#!CH IS
<br />
<br />::~:'.:~::E=RYFORVITALRECOROS. . /JiJlP~
<br />
<br />NOV ;,-- --' - ~ -- %;CO!W@
<br />LINCOLN, N~B~A2JlP.i 200600 376 H~~:~~-REQJ~
<br />"'-=-H ;-.;.1~~~=~,:;~,~;:'~<' _ -"
<br />____________~TATE ~:_:BRA_~KA- DEPAR~~~;;f1fAii~Qtp~~~~VI~ES FINA~~~V~pr~T(l5-- .121n
<br />
<br />.~ 1. DECEDENT'S.NAME (First, Middle, Last, Suffix) 2, SEX . --3~ DATE OF DEATH 2MO" D.y, Yr,)
<br />'j!:,___u_ MElr:~-~r-~-!_---!~-~-~-'-~?iOle~---_-------- Female ctober 8, 2005
<br />
<br />r.I.":.11~1..,.,f.'.!.: 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5., AGE-L.st Blrlhd.y_.5b,UNDER lYE_~~, 5c, UNDER I DAY 6_ DATE OF BIRTH (Mo" Day, Yr.)
<br />'~~;W: (Yrs,) MOS. DAYS """HOU"RS ----MiNs.
<br />,.-.,,,i\f k 72 N vember 16 11932
<br />'i~~ii Storm La e, Iowa 0 , .
<br />i,iJ:(~t, 7, SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />i'f4t 7-34-6726 1:iill1.ETIAl.:
<br />~'~~
<br />- .~ :.~':";:: ;'~ "~';"~':"~ ::.:"... :' """''''---~
<br />
<br />-I;''' Be CITY OR TOWN OF DEATH (Include Zip Gode)
<br />41~ Grand Island 68801
<br />-, ~
<br />'ffi1f1i4 9a RESIDENCE.STATE 9b. COUNTY
<br />~~[ Nebraska Hall
<br />tttllX: 9d, STREET AND NUMBER
<br />'~);~,--.11Q_~_ Woodridge Lane
<br />
<br />1.1 ::::~:~,::::::: ::,:::.:"~ =.:::.~ ~"::~ ".'00 '""::":: ~O:'. ''': ::'::: 'm"" ".," """ ...,. ...,
<br />
<br />,\1.1;:;' 11, FATHER'S-NAME (First, Middle, L.st, Sulllx) 12, MOTHER'S-NAME (Flrsl, Middle,
<br />~I}'$ Everett W. Martin Phyliss
<br />F~fi --';:JEVER-I;'iu,;'--AR~~D-~ORC~S? Giv~-~ates of~~;~;ce if yes. 14a.INFORMANT-NAME
<br />''", :111\:1:
<br />~~~~. (Y.s, no, or unk) NoR a I phS t ole s
<br />
<br />~~Jg 15. :::r~s~ OF DI~~:~::I:~ r~
<br />
<br />j:{\\;t o Cremation 0 Entombment 16d CEME ERY, CREMAr&i~THER L
<br />:'!~I~r~:~.{::;
<br />,j.~""'."
<br />/i '~V;:,~\,;
<br />'ki'~";
<br />~!:[~~
<br />
<br />.
<br />
<br />\
<br />
<br />U Inpetlenl
<br />
<br />QII:!!:B:
<br />
<br />o Nursing Home/LTC 0 Hospice Facility
<br />
<br />LJ ER/Outpatlenl
<br />
<br />00 Decadent's Horn:
<br />
<br />0000\
<br />
<br />o Olher (Speolfy)
<br />
<br />Bd, COUNTY OF DEATH
<br />Hall
<br />
<br />9c, CITY OR TOWN
<br />Grand
<br />
<br />Island
<br />
<br />"',
<br />
<br />
<br />91. ZIP CODE
<br />68801
<br />
<br />gg, INSIDE CITY LIMITS
<br />
<br />il!i YES 0 NO
<br />
<br />Maiden Surname)
<br />McGill
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Husband
<br />
<br />
<br />16b, LICENSE NO,
<br />
<br />1071
<br />
<br />16c_ DATE (Mo_, Day, Yr.)
<br />ovemher 1, 2005
<br />
<br />CITY /TOWN
<br />
<br />STATE
<br />
<br />I nm~ n_n~_~me t e r y_______________,~_,____Inma n ,
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Streel, City or Town, St.le)
<br />
<br />o Removal
<br />
<br />o Other (Specify)
<br />
<br />Nebraska
<br />
<br />
<br />lip Code
<br />
<br />d\
<br />lB, PART I. Enler Ihellilait1Jlf.Jl'ent~ndlse.ses, Injuries, or complloatlon'nth.1 directly caused Ihe dealh, DO NOT enter lerminal evenl. such as cardiac arresl,
<br />respiralory arre.l, or venlrlcular fibrilla lion without showing Ihe etiology, DO NOT AaaREVIATE_ Enler only ona causa on a IIne_ Add additional lines if nec....ry,
<br />
<br />IMMEDIATE CAUSE (Fin.1
<br />dl..... or oondltlon r..utllng
<br />In dealh)
<br />
<br />IMMEDIATE CAUSE,
<br />
<br />(.) ~ ~~~ c U-~~(\.t)rv::-..\'____.s~~~__ ~_0- ~t\~-..J^
<br />
<br />DUE TO~~EQUENCE OF:
<br />
<br />onset to deelh
<br />
<br />('(\Q~~t.
<br />
<br />onsello death
<br />
<br />Saquentlally lI.t conditions, if (b)
<br />any, leadln910 thec.use 1I.,ed DUE TO, OR AS A CONSEQUENCE OF:
<br />on line a.
<br />Enlarlho UNDERLYING CAUSE
<br />(dl..... or Injury Ih.t Inltlat.d (c)
<br />thaevenl. ra.ultlng In dealh) DUE TO, OR AS A CONSEQUENCE OF:
<br />lASf
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />1...._
<br />I on.al to dealh
<br />I
<br />I
<br />
<br />19, PART II. OTHER SIGNIFICANT CONDITIONS,Conditions conlributing to tha death but nol resulting in Ihe undarlying causa givan in PART I.
<br />
<br />19, WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />o YES ~NO
<br />
<br />20_ IF FEMALE,
<br />hi pregnanl within paS! year
<br />o Pr.gnanl .1 11m. of dealh
<br />o Not pregnant, but pregnant within 42 days of de.th
<br />o Not pregnant, but pregnanl43 days 10 1 year before death
<br />o Unknown if pregnant within the past year
<br />
<br />21'_ MANNER OF DEATH
<br />b,..tur.1 0 Homicide
<br />
<br />o AcoldenlO Pending Invesllgatlon
<br />
<br />U Suicide U Could nol be determined
<br />
<br />21b, IFTRANSPORTATION INJURY 21c, WAS AN AUTOPSY PERFORMED?
<br />U Drlv.r/Operator
<br />
<br />U Pass.nger
<br />
<br />U YES
<br />
<br />~O
<br />
<br />o Pedestrian
<br />
<br />21 d, WERE AUTOPSY FINDINGS A V AILABLE TO
<br />
<br />o Other (Specify)
<br />
<br />COMPLETE CAUSE OF DEATH?
<br />o YES ~O
<br />
<br />
<br />DYES 0 NO
<br />
<br />
<br />22a, DATE OF INJURY (Mo" Dey, Yr,)
<br />
<br />22b, TIME OF INJURY 22c, PLACE OF INJURY.At home, larm, .lr.el, faclory, offic. building, construction .11., .10, (Speclly)
<br />m
<br />
<br />22d, INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY" STREET & NUMBER, APT, NO,
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23., DATE OF DEATH (Mo" Day, Yr,)
<br />October 28, 2005
<br />
<br />24a, DATE SIGNED (Mo_, Day, Yr_)
<br />
<br />24b, TIME OF DEATH
<br />
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<br />.000
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<br />81;
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<br />
<br />24c, PRONOUNCED DEAD (Mo" Day, Yr,) 24d, TIME PRONOUNCED DEAD
<br />
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<br />
<br />24a. On ths basis of examination and/or investigation, In my opinion death occurred at
<br />the lima, dala and pl.ce .nd due 10 the oeu..(.) slated, (Signature and Tille) ...
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />o YES 0 NO 0 PROBABLY UNKNOWN 0 YES 0 NOI Appllo.ble If 26. Is NO U YES NO
<br />-.--.--.----- ..-
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. or Print)
<br />John J. Cannella M.D. 729 N. Custer Ave. Grand Island, Nebraska 68803
<br />
<br />2Ba_ REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b, DATE FILED BY REGISTRAR (Mo" Day, Yr,)
<br />
<br />NOV 2 2005
<br />
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