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<br />STATE OF NEBRASKA
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<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND H.UMAN SERVICES
<br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIfJ!~~!iD ON FILE WITH
<br />THE NEEiRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITA~sTArl$,J1g~N, WHICH IS
<br />
<br />:::;::~::::::;TORY FOR VITAL RECORDS. .i....~i~~.~!k....-- .. ':.,~o ',\;' -~J~~-~.-.:~~~._." ....~.
<br />--. .~ - T~'''4TJ!.NL~Y~~~OOPER
<br />NOV 0 7 2005 ~'~'CiAssisTANtSiATERg;/STRAR
<br />LINCOLN, NEBRASKA 2 0 0 6 0 0 3 7 7 '- ~,\; ''ff~LTH ANDNU.titAN2~ERVICES
<br />
<br />- -
<br />
<br />-- .;, "::;",;"
<br />
<br />STATEOFNEBRASKA-DEPAR~~~;rF~~~;~N~~U~~~~~VIC~$""FJ~f'INDSUPPORT D~ 1 7 7
<br />
<br />
<br />1. ~ECEDENT'S~~AME (~;Iiet t=-~:;~-~~ ~a~-" SUfflx)-- 2'5scF,Eu~NmD""~RlleDAY 63,ODrA~T~E~O;F;:BeIER~TTHH((M_Mloo.',9DD'a~vY,'Y~r',,)~~~_....,
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 50, AGE-L~s;' ~;;;-~~~~R I Y~A~. c
<br />Hildreth, N-ebI'frSka - (hI.. ~2 I Me~.cAYS HOURS .MINS'IMay 3, 1923
<br />
<br />7. SOCIAL SECURITY NUMBER Ba. PlACE OF DEATH
<br />
<br />
<br />507-18':"."4064
<br />
<br />Bb. FACiliTY-NAME (If nol Instilulion, give Slreol and number)
<br />
<br />o Inpallanl
<br />
<br />J:tQSf1lli:
<br />
<br />illlIEA: 0 Nursing Home/LTC 0 Hospice Facllily
<br />
<br />o ER/Oulpalienl
<br />
<br />:&l Decedent's Home
<br />
<br />912 West 4th
<br />
<br />UD:YI
<br />
<br />o Olhor (Specify)..
<br />
<br />BC. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island
<br />
<br />ed, COUNTY OF DEATH
<br />Hall
<br />
<br />9aRE;:E~;::~a lUNTYHa~'I' '=rC~~:~~\sl~nd
<br />9dST;~;AN~~:B~R 4th - --'--'-~~~'N-~ 91 ZIP~O~~Ol_eg~:~~:CITY~~~~
<br />
<br />lOa. MARITAL STArUS ATTrME OF DEATH 0 Married 0 Never Married 10b. NAME OF SPOUSr:. (First, Middle, Lasl, Suffix) If wife, give maiden name,
<br />
<br />o Married, bUI separalod ~Widowed 0 Divorced U Unknown
<br />
<br />Elmer F. Hatch
<br />
<br />(Deceased)
<br />
<br />11, FATHER'S-NAME (First,
<br />Charles
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />Suflix)
<br />
<br />12. MOTHER'S.NAME (Flrsl,
<br />
<br />Mlddlo,
<br />
<br />Maiden Surname)
<br />
<br />Ruhs
<br />13. EVER IN U,S. ARMED FORCES? Glvo dales of ,ervfea if yes. 'j'I.4a.INFORMAN-T-NA...ME
<br />(Yes,nO,orunk.) No James Hatch
<br />
<br />15~:~1:~ OFOl;::~::~:- 16a EMS' ~ SI~NATUrRf?, /J '. .
<br />""-- A.. IJ ilct- L ~.
<br />1 Bd, CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />T.
<br />
<br />Grace Post
<br />
<br />
<br />...3.......-.. -.....-..
<br />14b, RELATIONSHIP TO DECEDENT
<br />
<br />
<br />.., '''''",OOS ~~~~~ ~;~O;~:'}005
<br />
<br />CITY !TOWN STATE
<br />
<br />
<br />o Cremallon 0 Enlombmonl
<br />
<br />o Romoval 0 Olhor (Specify)
<br />
<br />Anatomical Board of Nebraska
<br />
<br />Omaha, Nebraska
<br />
<br />.-..---.-..
<br />17a, FUNERAL HOME NAME AND MAiliNG ADDRESS (Slraol, Ci'y or Tovm, Slale)
<br />Apfel Funeral Home 1123 West Second,
<br />
<br />-',''!i,..,
<br />PART l. Enter the ~venl.s.--disaases, Injuries. or complicatlons--thal directly caused the death. DO NOT enter terminal events such as cardIac arrest,
<br />respiratory arre,l, or ventricular fibrillation without showlnglhe etiology. DO NOT ABBREVIATE, Enlar only one cause on alino. Add addllionalllnes if nocassary.
<br />
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onsello death
<br />
<br />(e) Card; opulmonary arrest __.._.__
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In doalh)
<br />
<br />1 unknown
<br />onset to dealh
<br />
<br />'},i';"{ Sequenllollyll.loondlliono,lf (b). Hypertens; on
<br />J:,1:.t1 any, leadIng 10 Ihe eau.ellaled -ouiJO OR AS A CONSEQUENCE OF:
<br />
<br />'I:,t!lt~l ~~~~~:'UNDERLYINGCAUSE '
<br />;.' ...~. ,.t.,.,. (dlaease or Injury thaI Initialed (e)
<br />lr/fJ IheevenloresulllngIn dealh) DUE TO, OR AS A CONSEQUENCE OF:
<br />1\*'" lA'iT
<br />:I~~.l~ii.h
<br />1':',~1()4.
<br />II:':rr!\"
<br />:;~~1: - ';8. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions conlrlbulinglo Iha dealh bul nol ..Sulllng in the underlying cause given in PART I.
<br />
<br />;~~
<br />i~...
<br />
<br />'il' 20.IF FEMALE: 21., MANNER OF DEATH 21b, IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />'R 'if ~ 0 0 Driver/Operalor
<br />".".'.~. %.,:,' ~ Nol pregnant wilhin pasl year Nalural Homicldo U YES lS:J NO
<br />o Passengor
<br />:::; .', 0 Prognant allime of dealh 0 AccidenlO Pending Invealigalion
<br />j. 0 Pedestrian
<br />:""E' 0 Nol pregnant, bUI prognanl wilhin 42 days of doalh 0 Suicide 0 Could nol be delermined 21d. WERE AUTOPSY FINDINGS AVAilABLE TO
<br />o Nol pregnanl, bul pregnanl43 days 10 1 year bofore dealh 0 Olhor (Spacily) COMPLETE CAUSE OF DEATH?
<br />a
<br />o Unknown if pragnanl wllhin Iha pasl yoar U YES XQI NO C"
<br />
<br />~2~OATE OF "INJU~Y:(MO" LJ;y~r;~-::--j =TlMF::~~LACE OF INJURY.Atho-';;; la;m,'~I;~el, la~lory, ofllc. building, cO~S:UCII~~-slle'~I~. (s~~flyi ;.5
<br />
<br />
<br />22d INJURY AT WORKi~IBE HOW INJURY OCCURRED' C.)
<br />OYES ONO~._
<br />~-- - ----- ., --- ~
<br />22f.lOCATiON OF INJURY - STREET & NUMBER, APT. NO. CITYITOWN
<br />
<br />: unknown
<br />
<br />I onsst to deatl1
<br />1
<br />I
<br />I.
<br />
<br />onsel 10 dealh
<br />
<br />(d)
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTEO?
<br />
<br />~ YES 0 NO
<br />
<br />
<br />.-::.:]
<br />
<br />";",1...._
<br />
<br />'-1
<br />
<br />, ZIPcbCiE
<br />
<br />ST!\fE
<br />
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<br />c.")'.:=:J
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr,)
<br />October 24, 2005
<br />
<br />24b. TIME OF DEItrH""
<br />1538 ~
<br />
<br />24d. TIME PRONOUNCED DEAD
<br />1738 m
<br />
<br />23a, DATE OF DEATH (Mo" Day, Yr.)
<br />
<br />z,...
<br />>-~ !Ii!
<br />..QS:"!a:
<br />"i~Q
<br />'Gi:r~>-
<br />Q,Q..:.(.,J
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<br />u UJ z
<br />llz:l
<br />,!!~8
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<br />00
<br />
<br />Hall Count Att rney
<br />26b. WAS CONSENT GRANTED?
<br />
<br />Nol Applicebleil 26a is .~~ YES ~ NO
<br />
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<br />~~
<br />]-
<br />'Gig!
<br />c.:Z:~
<br />E""z
<br />0"'0
<br />tJ,f:
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<br />t2~
<br />
<br />23b, DATE SIGNED (Mo" Day, Yr.)
<br />
<br />23C. TIME OF DEATH
<br />
<br />240. PRONOUNCED DEAD (Mo" Day, Yr,)
<br />ctober 19, 2005
<br />
<br />m
<br />
<br />23d. To the baSI of my knowledge, death occurred at the lIme, dale and place
<br />and duo 10 Ihe causo(s) slaled. (Signaluro and T.ille ) "
<br />
<br />248. On the basis of examination and/or Investigation, in my opinion death occurred at
<br />Iha timo, dalo and place and duolo Ih. cause(s) slaled. (Signalure and Tillo)"
<br />
<br />fd---
<br />
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />.. 0 Y!,~._[JNO.. U PROBABtY, =-~ ~NJ<Ng)iitL Q YES ~ NO
<br />27. NAME, TITLE AND AODRESS OF CERTIFIER (pHYSICIAN, CORONER'S'PHYSICIAN OR COUNTY ATTORNEY) (Typa mlt)
<br />Mark J. Young, Hall County Attorney, 231 South Locust
<br />
<br />2Ba. REGISTRAR'S SIGNATURE
<br />
<br />St., Grand Island, NE 68801
<br />
<br />
<br />2Bb. DATE FILEO BY REGISTRAR (Mo" Day, Yr,)
<br />
<br />NOV S 2005
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