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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 ~~:~Z~~~V~~~
<br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL F!~fc=-=-,,-. _ HICH IS
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT~!!~-cS~~T!Pl!X(~=-.
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<br />::;:::::~::;TORY FOR VITAL RECOROS. ~Pliit~~~R
<br />MAR 2 0 2006 2006 0 3 7 0 1 . AsStSTMn S~'RgGiST~R
<br />LINCOLN, NEBRASKA H8ALmc~NI}.HU~~.~ ~jR.~~fjES
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<br />,~= -, =,=.:~.-::. . -~ .
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FU-lANC&ANB'SUPPORT
<br />_9ERTIFI~ATE OF DEATH --0-6 ~2---1---8-7-
<br />1 DECEDENrS.NAME (First, Middle, I"ast, SuffIX) 2 SEXl ~DATE W' ~~TH (~'b8t", Yr)
<br />Duane J Newberry Ma e arc,
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<br />4 C~Y-AND STATE OR ;ERRITOR~, OR FO'REIGN COUNTRY OF BIRTH '5a AGE.Last BlrthldY .5b UNDER'l YEAR . 50 UNDER ~DAY 6 DATE OF BIRTH(MO., D.y, Y~
<br />(YTs) MOS DAYS HOURI:MINS.
<br />Stapleton, Nebraska 80 5 7 October 7, 1925
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<br />~----~._-- -~ __-------L- _ _ _ _ _
<br />'ooo~,~"'~'"_" r"~"''''~
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<br />~ 0.8 - 4 6 ~7 ~ _ _ ___ _ _ liQSEJIAJ.. Q(lnp.llanl Q!]jf;EJ: 0 Nursing Home/LTC 0 Hospice Facilily
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<br />8b. FACILITY. NAME (II nol Instllutlon, give streal and number) 0 ER/Outpallent 0 Decedant's Home
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<br />St. Francis Medical Center
<br />o [l)\ 0 Otbar(Speclfy)_ __._
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<br />Bc. CITY OR TOiilN OF'DEATH (IncludaZipCoda) '-- -. - ---reHid~a C01UN1TY-OFDEATH- -'-.- -
<br />Grand Island, 68803 __~
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<br />~a:bs:~~Ek:T~-----J!C~il -.--.--~~~~dOw~sland ~-
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<br />ld~slR1ET~~Nu~~r'~~~-' ---- - - ~APTNO J gJ6Zi~08) - ~g: INSIDE CITY LIMITS
<br />J_ _L ~ YES 0 NO
<br />lOa. MARITAL STATUS ATTiME OF DEATH)] M.rrled 0 Never Marr1ed lOb NAM~SPOUSE(FI;;;:-MIddla, LaM:SUItIX) II wife, give maiden nama .- - ",-
<br />Beth Dancer
<br />o Mam.d, but separated 0 Widowed W Divorced 0 Unknown
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<br />11. FATHER'S'N~h(lTam H~bd~~~ewb~rry S;;;fi:==e MOTHER'S'NAMEOP~l- I~~~e'-. Mai1.fal1.~me)
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<br />;:es~~:,R:~Nu~k~.~~DFORCES?'GIVe d~I~~-e;~lce 11 Ye~Ji~thMANTN:~berr;---U'--' ~bi Ri~TiONSHlPTO-DECEDENT
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<br />15~::,~~OFDI~~:::I:~'J:6;EMBttk:;rRf7 ~ll:;;- _ bLnNiEN~'-= ~~;:~(~?'oD:V';~06
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<br />Mcremation 0 Entombmanl 16d CEMETERY, CREM~OR OTHER LO~- CITY I TOWN STATE
<br />o Ramoval OOtber(SpeCllv) Westlawn Crematory Grand Island NE
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<br />_w_________ ~.,_,
<br />17a. FUNERAL HOME NAME AND MAt LING ADDRESS (Slreel, Clly or Town, Stale)
<br />Livingston-Sondermann F.H. 601 N.
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<br />PART I. Enter the C,II~~,s...dlsea5es, injuries, or complicalions--thal dIrectly caused the dealh. DO NOT enter terminal events such as cardiac arrest,
<br />resplr.tory arrest, or ventricular tlbrlllation wltbout sbowlng the ellology. DO NOT ABBREVIATE" Enter only one cauee On a line" Add additional line. If neces.ary" I
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<br />IMMEDIATE CAUSE' k ~ '" :,xfn$at to deatb
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<br />:~:::~:=::.. ~:uo~ r~~--+l.",.;~
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<br />Indealb) I
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<br />SequentieIlYIiSICOndll'onS,II..!~ --I~~~-/1~~ /)A... _.~__
<br />any, leading IOlhecaus.lisled DUE TO. ORASACONSEOUENCE OF -V-=-~r I on.etto de.tb
<br />onllM8. I
<br />EnlertheUNDERLYtNG CAUSE I
<br />(bdISease,orln)UrYlhl.llnlllaled (e) ._,,_._ .___.._ ___'__'__ _.__ _-----L..._
<br />I eeven .,esulllng n dealh) DUE TO, OR AS A CONSEQUENCE OF: I onset to deatb
<br />LASr
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<br />(d)
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<br />18 PART II OTHER SIGNIFICANT CONDITiONS.c~ndltlOns contributing ~de~lhbulnot reSUlting m Ibe underlYlng'causa glv;n in PART 1'--']:19 WAS MEDICAL EXAMIN-E~
<br />OR CDRONER CONTACTED?
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<br />o YES ~ NO
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<br />20, IF FEMALE: 21a. MANNER OF DEATH 21 b. iF TRANSPORTATION INJURY 21 c. WAS AN AUTOPSY PERFORMED?
<br />W. iti:Naturel. 0 Homicide ODrlverlOperalor .Y
<br />Not pregnant wltbln past yeer 0 YES ~NO
<br />o Pregnant al lima of d..tb 0 AccidentO Pendinglnve,lIgetlon 0 Passengar ___ _ .._.__
<br />o Not pregnanl, but pregnant within 42 days 01 deatb 0 Suicide 0 Could not be detarmined 0 Pede'trlan 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Not pregnant, bUI pragnanl43 d.ys 10 1 y.ar belora deatb 0 Otber (Spacify) COMPLETE CAUSE OF DEATH?
<br />o Unknownllp,egnenlwilhintbep.slyeel ____ 0 YES 0 NO
<br />__ 22e DATE OF INJU~Y (Mo, Day, Yr) r. TIME: OF INJu~T 220. PLACE OF INJURY.AI h~'';e, term, slreet, factory, olllce bUlldin:, conetru~'~n site. elc (Specllyj -_.
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<br />22d INJURY AT WORK?]2' DESCRIBE HOW INJURY OCCURRED
<br />DYES 0 NO
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<br />22f. LOCATION OF INJURY. STREET & NUMBER, APT. NO, CITYIfOWN STATE ZIP CODE
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<br />2S.. DATE OF DEATH (Mo" Day, Yr,)
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<br />24a. DATE SIGNED (Mo" Day, Yr.)
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<br />24b, TIME OF DEATH
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<br />~DIDTOBACCO USE CONTRIBUTIOT ~,HAS ORGAN OR TlSSU'E DONATION BEEN CONSIDERED?
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<br />-:ii'~J:'~~:~~~~R~FlER ~P~;S~~~:'~ORONER~ P~~:ICIANOR COUN~~RNEYL (Type or Prlnt)-'
<br />DR Gordon J. Hrnicek MD 729 N. Custer Grand Island NE
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<br />240. PRONOUNCED DEAD (Mo., Day, Yr.) 24d, TIME PRONOUNCED DEAD
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<br />24e. On the basis of Elxamlnation and/or invesUgation, In my opinion death occurred at
<br />tbelime, date end pl.ce and due to Ibe causers) stated, (Signatura and Title) "
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<br />~ WAS CONSENT GRANTE:D?
<br />Not Applicebl!~a_l. NO_l!~ O_~.
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<br />68803
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<br />28a, REGISTRAR'S SIGNATURE
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<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
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<br />MAR .1 7 2006
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