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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 R.1gt;t:J!lD .000FILIf WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT~~~~~1JJjjfif-WHICH IS
<br />
<br />:~:~:S::::RY FOR VITAL RECORDa ~J~
<br />:'2 f7f. "'S.~~tiER
<br />FEB 2 1 20(JF ~sS~TM1I:::8",E~IS,",AR
<br />LINCOLN, NEBRASKA 2 0 0 6 0 16 G 0 HEAtT-I{.ANO HUMAN~\?pE~
<br />
<br />..
<br />.. -
<br />
<br />~
<br />
<br />. .".
<br />STATE OF NEBRAsKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE5'-fiNA~'Arli6'-'SUPPORT
<br />.CERTIFIGAII; OF DEATtL~'.' 06 . 2.12A.4-
<br />
<br />1, OECEDENT'S.NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Dey, Yr.)
<br />
<br />Earl
<br />
<br />Elwood
<br />
<br />Dallv
<br />
<br />5a. AGE.Last 8irthd.y
<br />(Yrs.)
<br />
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />Male
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />~.!1, 2006
<br />6. DATE OF 81RTH (Mo.. Day, Yr.)
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF 81RTH
<br />
<br />90
<br />
<br />1915
<br />November 14, 2eeD
<br />
<br />7 SOCIAL SECURITY NUM8ER =ra PLACE OF DEATH
<br />
<br />50.b.Q.5=71 M . . . . 1:iQSEJIAl.
<br />8b. FACILlTY.NAME (II not rnstrtutron, give .treot and number)
<br />
<br />Grand Island Veterans Hooe
<br />
<br />- ----
<br />
<br />o Inpatl.nt
<br />
<br />Q:t!:illJ:
<br />
<br />~urslng Home/LTC U Hospice Facility
<br />
<br />o ER/Outpatl.nt
<br />
<br />o D.cedent's Homo
<br />
<br />8e. CITY OR TOWN OF DEATH (Include Zip Code)
<br />GraI?:9Island, Nebraska 68803
<br />
<br />~~~~;::ATE'- [:~t
<br />
<br />9d. STREET AND NUMBER
<br />
<br />o [l)'\ 0 Other (Specify)
<br />.. ._, ~d. CO, U"NTY OF DEATH
<br />Hall County
<br />- ~::~TO~:lan~-'-' .
<br />
<br />. - '-~NO '19~;;~DE - ~iDE'CITYLlMITS
<br />____L 3 1 .___J.JO YES 0 NO
<br />lOb. NAME OF SPOUSE (First, Middle, Last, Suflix) If wife, give maiden neme.
<br />
<br />.2612---Nor.th Car.lpt-nn
<br />lOa. MARITAL STATUS AT TIME OF DEATH 0 Morried 0 Novor Married
<br />
<br />U Married, bUlseparated :&J WIdowed 0 Divorced [J Unknown
<br />
<br />Doris Hughes
<br />
<br />11. FATHE;R'S.NAME (First,
<br />Jom
<br />
<br />Middlo,
<br />P.
<br />
<br />last,
<br />
<br />Suffix)
<br />
<br />l-;~'MOTHER'S'NAME (First,
<br />'- Carrie
<br />
<br />Mlddlo, Maiden Surname)
<br />
<br />Dal!x.
<br />
<br />------Maurer.
<br />14b, RELATIONSHIP TO DECEDENT
<br />
<br />Niece
<br />16c. DATE (Mo., Day, Yr.)
<br />February 9. 2006
<br />
<br />13. EVE;R IN U.S. ARMED FORCES? Give dates of serviCe If yes. 14a.INFORMANT;NAME
<br />
<br />" (Ye" no, or unkYes._l
<br />15. METHOD OFDISPOSITION
<br />I;liI Burial 0 Donation
<br />U Cremation 0 E;ntombment
<br />
<br />
<br />-1 O~_ . Margaret .florgenfreir
<br />16a.EMB,AALL~Mj.R~r"NN;;;!'A',7 /7~'" , 16b'LIC,ENSE~0; ".
<br />./?/J "--UJ ... /2 "ICI
<br />16d. CEME;TE;'RY, CREMATO~ OTHER LOCATION .. CITY /TOWN
<br />
<br />STATE
<br />
<br />
<br />o Removal U Other (Specify)
<br />
<br />Shelton Qemeterv
<br />17a. FUNERAL HOME NAME; AND MAILING ADDRESS (Stroot, City or Town, State)
<br />
<br />Shel,ton
<br />
<br />Nebraska
<br />
<br />PART I. E;ntor the l<haIn.<l!"Y'[I~--di'ea'es, injurle', or complleation,..thal directly cau,ed Ihe death. DO NOT onter termlnel events such a, cardlec errest,
<br />respiratory errest, or ventricular IIbrlllation without ,howlng the etiology. DO NOT ABBREVIATE. Enler only one cau.e on a line, Add eddltlonalline, if nece,sery.
<br />IMMEDIATE; CAUSE;:
<br />
<br />onsel to death
<br />
<br />IMM~DlATE CAUSE (Final
<br />disease or condition resulting
<br />In death)
<br />
<br />(a) Cardif2respi:c2!...to:tYEailw:;:~ ..~
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I
<br />__-----L.....?A~ 4~_ Hours
<br />I onset to death
<br />
<br />Sequontially list conditions, if (b) End Stage Dementia
<br />
<br />any,le.dfngtothocauselleted DUE TO, OR AS A CONS'EQUENCE OF:
<br />on IInee,
<br />Enter tho UNDERLYING CAUSE
<br />(disease or Injury that Initiated (c)
<br />tho.vontsre.ultlngin doath) DUE TO, OR AS A CONSEQUENCE; OF:
<br />LAST
<br />
<br />Mixed Type
<br />
<br />) 5 Years
<br />
<br />ansa I to death
<br />
<br />(d)
<br />
<br />L
<br />I on,etto deeth
<br />I
<br />I
<br />
<br />18. PART II. OTHER SiGNIFICANT CONDITIONS,Condition, contributing to the deeth but not ro,ultlng in the underlying cau,e given in PART I.
<br />
<br />Angina, Dysphagia, Dyslipidemia
<br />
<br />20. IF FEMALE:
<br />
<br />21a.MANNER OF DEATH
<br />is\,atural 0 Homicide
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTE;D?
<br />
<br />DYES :&<NO
<br />
<br />21 b.IFTRANSPORTATION INJURY 21 c, WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operetor
<br />
<br />tr.
<br />III
<br />m
<br />
<br />;u,
<br />
<br />o Not pregnanl within past year
<br />o Pregnanlet time of death
<br />o Not pregnant, but prognanl within 42 days of death
<br />o Not pregnant, but pregnant 43 days to 1 year before death
<br />o Unknown if pregnant within the past year
<br />22a. DAT~OFINJURY (M~"D;y, Y;,Jl2fuTIMEOFlNJUR:
<br />
<br />'22d.1NJURY ATWORK?T2e DESCRIBE; -HOW INJURy'OCCURRED
<br />o YES 0 NO
<br />------- - --- -
<br />221. LOCATION OF INJURY. STREET & NUMBE;R, APT. NO.
<br />
<br />o AccldenlO Pending Invesflgstlon
<br />
<br />o Passenger
<br />U Pedestrian
<br />
<br />DYES
<br />
<br />)g{N0
<br />
<br />
<br />o Suicide LJ Could not be determined
<br />
<br />o Other (Spoclfy)
<br />
<br />21 d. WERE AUTOPSYFINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />220, PLACE OF INJURY.At home, farm, street, faclory, ollice building, con,tructlon site, elc. (Speoify)
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZiP CODE
<br />
<br />23a. DATE OF DEATH (Mo" Day, Yr.)
<br />February 4, 2006
<br />
<br />24a. DATE SIGNED (Mo" Dey, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />23C, TIME OF DEATH
<br />3:40 P. m
<br />
<br />z>-
<br />~~~
<br />H~
<br />o..a..<::,
<br />E.'" ~ Z
<br />011: 0
<br />"ILl
<br />llz:>
<br />~~8
<br />o ~
<br />() 0
<br />
<br />m
<br />
<br />240. PRONOUNCED DEAD (Mo., Dey, Yr.) 24d. TIME; PRONOUNCED DEAD
<br />
<br />m
<br />
<br />24e. On the basis 01 examination and/or invesligation, in my opinIon death occurred at
<br />the time, dele end place and due to the causers) stated. (SignalUre end Title) T
<br />
<br />26b, WAS CONSENT GRANTE;D?
<br />
<br />----.9.YE~~ ~.~ Y~<?BA~LY U UNKNOW~ U~~n. , ~O.
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN', CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />
<br />~ M:";"=~::::~ M.D., Gran:! Island Veterans !lane, Grand
<br />
<br />^ ._..Not Applicable if 26a.i' NO U YES 0 NO
<br />
<br />Island, NE 68803
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR IMo" Dey, Yr.)
<br />
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