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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 ORIGIN.4LRECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL sTATTimcs SECTlQN, WHICH IS
<br />
<br />:::;::~~:::::~TORY FOR VITAL RECORDS. :~u=- '.__'. .':;1-'~'1:
<br />.NOV 152006 200611092 ~i..<~oo,..R
<br />ASSlSTkNTSTATE R.EG/$'fRAR
<br />HEAL tHJiND HU!,1/tof!iSEftYICES
<br />en .,.: .':~._.:..~i~-:~'~=~' ,. .::"7
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />\\
<br />
<br />- . -...-- -,-
<br />.: ~-:. ~ ~ _.~c:-.:
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERV;~~'S=: Fri~i!{tb~~ND SUPPORO 6 3 21 7 3
<br />________ CERTIFICATE9F DEATH '.' .. ..
<br />
<br />Bradshaw, Nebraska
<br />7, SOCIAL SECURITY NUMBER
<br />508-42-8133
<br />-----.----
<br />
<br />5a. AGE-Lasl Birthday 5b. UNDER 1 YEAR
<br />(Yrs.) MOS DAYS
<br />
<br />72
<br />
<br />50. UNDER 1 DAY
<br />- -
<br />HOURS MINS,
<br />
<br />3. DATE OF DEATH (Mo.. Day, Yr,)
<br />Octobe_r31,2006
<br />6. DATE OF BIRTH (Mo" Day, Yr.)
<br />
<br />DEC~D~NT'S-NAME (First,
<br />VirQinia
<br />
<br />Middle,
<br />Lee
<br />
<br />Last,
<br />
<br />Suffix) 2. SEX
<br />Female
<br />
<br />_Ha OftS
<br />
<br />4. CITY AND STAT~ OR TERRITORY, OR FOR~IGN COUNTRY OF BIRTH
<br />
<br />~~Y~,.1934
<br />
<br />6a. PLACE OF DEATH
<br />tiOSPi!AL:
<br />
<br />U Inpatient
<br />
<br />~: 0 Nursing Home/LTC 0 Hosplca Facility
<br />
<br />8b. FACILITY-NAME (If not Instllullon, give streel end number)
<br />
<br />o ER/Outpalient
<br />
<br />58 Decedent's Home
<br />
<br />14362 White Cloud Road
<br />
<br />000'.
<br />
<br />o Olher(Speoily)_.._
<br />
<br />8e, CITY OR TOWN OF DEATH (Include Zip Codo)
<br />
<br />8d. COUNTY OF D~ATH
<br />
<br />Nebraska____
<br />9d. STREET AND NUMBER
<br />
<br />Hall _
<br />
<br />J
<br />
<br />HalJ__
<br />
<br />...Cal.ro
<br />9a, RESIDENCE-STATE
<br />
<br />rOUNTY
<br />
<br />ge, CITY OR TOWN
<br />
<br />J4362 White Cloyd Road
<br />1 Oa. MARITAL STATUS AT TIME OF DEATH )1l Married 0 Never Married
<br />
<br />.. ~Slirn
<br />1ge...APT.NOj'9f.' Z..IP COD. ..E.
<br />
<br />_ _~ _68824
<br />lOb. NAME OF SPOUSE (First, Mlddl~, Lasl, Suffix) It wife, give maiden name.
<br />
<br />-,.-----.--.-
<br />9g, INSIDE CITY L1MIT..S
<br />o YES ~ NO
<br />
<br />o Married, bUI 'eparaled 0 Widowed 0 Divorced Q Unknown
<br />
<br />Middle, LaS!,
<br />
<br />Suffix) -] 12. MOTH-ER'S-N~ME
<br />
<br />Wade Haynes
<br />
<br />11, FATHER'S-NAM~ IF.lrsl,
<br />
<br />(First,
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />
<br />Leland Chrl"ti
<br />
<br />Vlrg~
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />(Yes, no, or unlNo
<br />15, METHOD OF DISPOSITION
<br />
<br />ne~
<br />
<br />nhJ!sband
<br />16c. DATE (Mo" Day, Yr. )
<br />
<br />.lB Burial
<br />
<br />o Donallon
<br />
<br />1148
<br />CITY /TOWN
<br />
<br />ember 4, 2006
<br />STATE
<br />
<br />[J Cre,nelion 0 Entombment
<br />
<br />o Removal 0 Other (Specify)
<br />
<br />Gothenburg Cemetery
<br />
<br />Gothenburg
<br />
<br />NE
<br />
<br />18. PART I. Enter the ~Q.tevent5.--dlseases, injuries, or complicaUonS--lhat directly caused Ihe death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arres!, or ventricular fibrillalion without showIng the etiology. DO NOT AB8REVIATE. Enter only ona cause on a line. Add addltlonallines jf necessary.
<br />IMMEDIAT~CAUSE: ~tLl?' 0 r~Y01(l) V'f CW)'\Q,1st-.
<br />
<br />tMMEDIATE CAUSE (Flnol ~4-- ....... -~~!D-l:Y1av P4lW rQ._/
<br />disease or condttlon resulting DUE TO,OR AS A CONSEQUENCE ry(: 'f'\
<br />In death) '7 vndQf:1 af\i )1LEUn1\.- t;..~ ~IO~
<br />Sequenllallyllstcondlllons,1t ~._ t .~ Ct~(,I~ ~:1;10I'\lJbRV' '-+1'1 ...
<br />any, loading to tho couse IIstod DUE TO,:OR AS'A cbNSEirUENCE OF: ,. r ----\ V
<br />
<br />~~t~~~h:'UNDERLYINGCAUSE . (OVOtU 0.11 C Q0'I Cb-l\..
<br />(dlsoas. or injury that Inlllated (c) ", . .
<br />lheevenls ro.ulllng In death) DUE Tb~OR AS A.CONSEQUENCE OF:..
<br />~
<br />
<br />
<br />Zip Code
<br />
<br />17a. FUNERAL HOME NAME AND MAILiNG ADDRESS (Streel, Clly orTown, State)
<br />Apfel Funeral Home 411 West 11th St. P.O. Box 126 Wood River Nebraska
<br />
<br />onset to death
<br />~AM
<br />
<br />I onssl to death
<br />I
<br />I.~
<br />I
<br />I onsello dealh
<br />I
<br />1".''-
<br />I
<br />
<br />onsel 10 deelh
<br />
<br />(d)
<br />
<br />.{
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions conlribuling to Ihe dealh bul not resulling In the underlying cau,e given In PART I.
<br />
<br />\I1arb€:p I r()~mfJfltt?v( al\~M.'01 I.Jtm ! lJ1PQ~I~
<br />
<br />
<br />,}o. IF fEMALE; 21a, MAj)iNER OF DEATH 21 b.IF TRANSPORTATION INJURY 21c, WAS AN AUTOPSY PERFORMED?
<br />__ ./ Ii! Natural 0 Homicide Driver/Ope lor . .- ".. ../
<br />~Not pregnant wllhln past year ,/ v 0 YES '-i)N..
<br />
<br />o Pregnant allime 01 deslh IJ AccldontO Pending Investigation Pesse ger ~'
<br />
<br />U Nnl pregnant, but pregnant within 42 days 01 deelll ede trlen ~/,. 21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />[J Suicide U Could nol be delermlned ~
<br />o e (Sp if. .-
<br />~ Nol pregnant, but pregnant 43 days to 1 year beloro death . I/COMPLETE CAUSE OF DEA~'.
<br />
<br />o Unknown if pregnant within fhe past year U YES 0 f\P"
<br />
<br />t 9. WAS MEDICAL EXAMINER
<br />OR CORONER C,ON)1<CTED?
<br />DYES cf'No
<br />
<br />23a. DATE OF DEATH (Mo" Day, Yr.)
<br />
<br />
<br />m
<br />
<br />22e, DATE OF INJURY (Mo" Day, Yr.)
<br />
<br />22b, TIME OF INJURY
<br />
<br />home, farm, streetl factory, office building, construclion sita, atc. (Specify)
<br />
<br />
<br />--22d-INJURY-ATWORK? - \ 220 DESCRI
<br />U YES 0 NO
<br />22f. LOCATION OF INJURY" STREET & NUMB R, AP. 0.
<br />
<br />CITYrrOWN STI\f~
<br />
<br />ZIP CODE
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />Am
<br />
<br />z>-
<br />,..:S ~
<br />.D\'!a:
<br />""'~
<br />i!>-
<br />'5.~iCC~
<br />g~~1'i
<br />"uJ Z
<br />"z"
<br />.DOO
<br />~a:u
<br />o ~
<br />() 0
<br />
<br />m
<br />
<br />240. PRONOUNCED DEAD (Mo., Day, Yr,) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examination and/or investigallon, In my opinion deatb occurred at
<br />the lime, dale and place and due to Ihe causo(s) slaled, (Slgnalure and Tille) "
<br />
<br />.1lI NO
<br />
<br />26b. WAS CONSENT GRANTED?
<br />t:-.:..
<br />NOI Applicable If 26a is NO 0. YES U NO
<br />
<br />R TISSUE DONATION BEEN CONSIDERED?
<br />
<br />Iloreta M.D.
<br />
<br />908 N. Howard
<br />
<br />Grand Island, NE.
<br />
<br />68803
<br />
<br />28s, REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY R~GISTRAR (Mo" Day, Yr.)
<br />
<br />NOV 1 3 2006
<br />
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