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<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 RECOIiPJI'(FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTlCS--$ECTiON;..'WI:Ilr;H IS
<br />
<br />::::::~:C7RY FOR WTAL RECORD& ~tt~:R'
<br />J AN 0 6 2006 2 0 0 6 0 15 8 8 ASSlsTANTMATE4lEGISTRAR'
<br />LINCOLN, NEBRASKA HEAi~[HcA1{D -'lI)MAN'SERVICES
<br />
<br />
<br />STATE OF NEBRA~KA - DEPARQ~~TtE19~I~NQt~~N:~~VICES FINANCE AN~ $U~~O~;05~' '14 657
<br />
<br />Ut'\I"
<br />~~~~. 1 DEC~_~E~:~_:_~_E i;~dore ~iTh~rt
<br />
<br />~:"I;;.I' 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />'1\<\
<br />I___~~ba ~ Nebraska
<br />
<br />I.~.~...{...;~~...., 7. SOCIAL SECURITY NUMBER
<br />.6~:f~; 508-16-9190
<br />rt~!:i~
<br />';jl~
<br />;i:L\I:::~~'
<br />"1~''''
<br />: ~,~,"~i
<br />n
<br />
<br />Lasl,
<br />Gec
<br />
<br />Sulfix)
<br />
<br />2. SEX
<br />Male
<br />
<br />3, DATE OF DEATH (Mo., Dsy, Yr.)
<br />December 2?1 2005
<br />
<br />6. DATE OF BIRTH (Mo" Day, Yr,)
<br />
<br />5a. AGE-Last Birthday
<br />(Yrs.) 83
<br />
<br />5b. UNDER 1 YEAR 50, UNDER 1 DAY
<br />__ '_.."..._0"'_'. _..
<br />MOS. DAYS HOURS MINS,
<br />
<br />July 12, 1922
<br />
<br />Ba, PLACE OF DEATH
<br />1::!.Q.SflIAJ.:
<br />
<br />CJ Inpatisnt
<br />
<br />QItf1;8;
<br />
<br />~Nurslng Home/LTC CJ Hospice Facility
<br />
<br />Bb. FACI.L1TY.NAME (If not Institution, give slreet and number)
<br />
<br />CJ ER/Outpallenl
<br />
<br />CJ Decedent's Home
<br />
<br />Grand Island Veterans Home
<br />
<br />UOCl\
<br />
<br />o Other (Speclly)
<br />
<br />,~
<br />
<br />Bo, CITY OR TOWN OF PE;ATH (Inolude Zip Code)
<br />Grand Island, Nebraska
<br />
<br />ed. COUNTY OF DEATH
<br />
<br />68803
<br />
<br />
<br />Hall Count
<br />
<br />
<br />9a. RESIDENCE.STATE 9b, COUNTY
<br />;'~ .,f Nebraska Hall
<br />
<br />;~~I' 9d "STREET AND NUMBER
<br />
<br />Ii ;1 ~~O W Capital Ave ._U"._,_~"._
<br />
<br />1 ' 10a MARITAL STATUS AT TIME OF DEATH 2il Married 0 Never Married 10b, NAME OF SPOUSE (First, Middle, lasI, Suffix) If wife, 9ive maiden name,
<br />
<br />;1 < 0 Married. but separated 0 Widowed U Divorced 0 Unknown
<br />~ ~
<br />L~, -11, FATHER'S.NAME (First,
<br />
<br />kfl!1t __ LO~~~_." (NMI) Goc
<br />
<br />'li)'iN 13, EVER IN US ARMED FORCES' Give dales of service If yes, 14a, INFORMANT-NAME
<br />:i~:f;; _"0'~,"~o,.o: unk )01/14/1943-04/05/1946 PhYlli~,"",~orra~~~JGOC
<br />
<br />
<br />!1' 15, ~::r~a~ OF PI~~:~::I:~ 16a E~~ LME(~LrJbld____ _ 16b, L1~~N~~
<br />
<br />"~Wi~! 18 Cremation 0 Enlombmenl 16d, CEME;TE;RY, CREMATORY OR OTHER LOCATION CITY /TOWN
<br />
<br />;WII$ 0 0
<br />:~r',~ Removal Other (Specify) Central Nebraska Cremation Service, Gibbon, Nebraska
<br />~li! '
<br />I~ -'17~ FUNERALHOME NAME AND MAILING ADDRESS (Street, City or Town, Stote)
<br />'\I~& Kleine Funeral Home, 3213 W North Front
<br />
<br />Island
<br />
<br />68803
<br />
<br />. "----eg, -INSIDE CITy-liMITS
<br />jl YES 0 NO
<br />-..........-.--'".....--
<br />
<br />91. ZIP CODE
<br />
<br />Phyllis Lorraine Neely
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S-NAME (FlrSI,
<br />Sophie (NMI)
<br />
<br />Middle,
<br />Smedra
<br />
<br />Malden Surname)
<br />
<br />14b. RElATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />16c, PATE (Mo" Day, Yr, )
<br />December 30, 2005
<br />
<br />STATE
<br />
<br />PART I. Enter the ~1ID'cnls--diseases. injuries, or compllcationS--lilal directly caused the death. DO NOT enter terminal event~ such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showIng lhe ellology. DO NOT ABBREVIATE. Enter only one cause on a line. Add addlllonalllnes if necessary.
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />disease or condition resulting
<br />In de.th)
<br />
<br />(a) Cardiopulmonary Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I
<br />I
<br />I
<br />I
<br />I
<br />_.L
<br />I
<br />I
<br />I
<br />
<br />S 5 Minutes
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onset to daath
<br />
<br />onset to dealh
<br />
<br />Sequentl.lly list condition., If
<br />any, leading to the causellsled
<br />on line 8.
<br />Ente, the UNDERlYING CAUSE
<br />(dl..... 0' Inlury Ihetlnltioted
<br />the events ,e.ultlng in death)
<br />lA'>T
<br />
<br />(b) pneUlTDnia (Recurrent)
<br />
<br />L 3 Months
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsello death
<br />
<br />(c)
<br />
<br />Congestive Heart Failure
<br />
<br />/" 1 Year
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF.
<br />
<br />Onset 10 death
<br />
<br />
<br />(d)
<br />
<br />18, PART II, OTHE;R SIGNIFICANT CONDITIONS-Conditions contribulin9 to the dealh but nol resulting In the undsrlylng cause given in PART I.
<br />Vascular Dementia, CVA with Aspiration
<br />
<br />19, WAS MWICAl EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />o YES IX NO
<br />
<br />o AooldenlU Pending Investigellon
<br />o Sulolde U Could nol be delermined
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />o Passenger
<br />
<br />o PedeSlrlan
<br />
<br />o Other (Specily)
<br />
<br />21 c. WAS AN AUTOPSY PERFORMED?
<br />
<br />20, IF FEMALE:
<br />o Not pregnant wllhln pasl year
<br />o Pregnant at time of death
<br />U Nol p'egnanl, bul plegnanl within 42 days of death
<br />o Nol pregnant, but pregnant 43 days 10 1 year before death
<br />U Unknown If pregnant within the past year
<br />
<br />21a. MANNER OF DEATH
<br />IXNalural 0 Homicide
<br />
<br />DYES aA NO
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES U NO
<br />
<br />22a, PAT~ OF INJURY (Mo" Day, Yr.)
<br />
<br />22b, TIME OF INJURY 22c; PLACE OF INJURY.AI home, farm, "'eet, factory, office building, construotlon slle, elc. (Specify)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />DYES 0 NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP COPE;
<br />
<br />23a, DATE OF DE;ATH (Mo" Pay, Yr.)
<br />December 26, 2005
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr,)
<br />
<br />24b, TIME OF DEATH
<br />
<br />23c. TIME OF DEATH
<br />4:15 P.m
<br />
<br />z>
<br />~~~
<br />"OIl!:
<br />n~
<br />c,D.. 4J; ~
<br />E ~UI t Z
<br />8ffi~o
<br />1!Z=>
<br />~~8
<br />815
<br />
<br />m
<br />
<br />23b, DATE SIGNED (Mo" Oay, Yr,)
<br />December 27 2005
<br />
<br />24c, PRONOUNCED DEAD (Mo" Day, Yr,) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d, To Ihe besl of my knowledge, dealh occurrad allha time, date and place
<br />and due to Iha causa(s) slaled. (Signalure and Tille) l'
<br />
<br />248. On the basis of examination and/or Investigation, in my opinion dealh occurred at
<br />the time, dale and place and duelo the causers) stated. (Signatur. and Tille) l'
<br />
<br />71/1
<br />
<br />
<br />2ea, HAS ORGAN OR TISSU~ DONATION BE;EN CONSIDERED?
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />25, OlD TOBACCO USE CONTRIBUTE T
<br />
<br />DYES }O[NO 0 PROBABLY 0 UNKNOWN 0 YES ;Q{NO
<br />-27:NAM~:TiTLE AND-ADDRESSOi' CERTii'iER(PHysiCIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Prlnl)
<br />M.A. Tonpkins, M.D., Grand Island Veterans Heme, Grand
<br />
<br />Not_Applicableil2ea Is NO U YES IJ NO
<br />
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />Island, NE 68803
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo" Pay, Yr.)
<br />
<br />JAN 4,2006
<br />
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