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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND fiJl/lffAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BEl-OW TO BE A TRUE COpy OF THE ORIGINAlfflECQlftif:iNflLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST4!fST~GS S"Ect1P'N,"~W/jICH IS
<br />THE LEGAL DEPOSITORY FOR V(TAL RECORDS.,,=='. 0"" "J '~\,
<br />
<br />DATE OF ISSUANCE M~'~~.~ ~c~, ,=~
<br />f~ v!i1TAJtit.EY-S. COOPER
<br />20070 10"18 ASSIS.TANT STATEa~tRAR
<br />H~#TftANO;'J~rjSERo/CES
<br />
<br />tl~JJJgg~SKA
<br />
<br />
<br />STATE OF NE..B. RASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCI:-ANtl sUPPO~ 6
<br />CERTIFICATE OF DEATH () ...
<br />-- "--.--.---".----".--.- ., ",.
<br />
<br />()07 r,
<br />3,t-.j
<br />
<br />1. DECEDENT'S-NAME (First,
<br />Raymond
<br />
<br />Middle,
<br />Lee
<br />
<br />Last,
<br />Stoulp
<br />
<br />Suffix)
<br />
<br />2.SEX
<br />Male
<br />
<br />3. DATE, OF DEATH (Mo" Dey, Yr.)
<br />September 16, 200
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sloan, Iowa
<br />
<br />5a. AGE.Last Birlhday
<br />(Yre,) 75
<br />
<br />5b, UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />6, DATE OF BIRTH (Mo" Day, Yr,)
<br />November 27, 1930
<br />
<br />7, SOCIAL SECURITY NUMBER - - -.-.-Isa. PLACE OF DEATH
<br />484-30-335 7 ~ HQSJ'J.:rAb:
<br />8b. FACILITY-NAME (If not inslilUlion, give street ."and nL:~ber) I
<br />
<br />'/Primrose Care Center
<br />
<br />o Inpatient
<br />
<br />QIl:!EB: 0 Nursing Home/LTC 0 Hospice Facility
<br />
<br />Bc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />
<br />N ~ ~-~:s k~-----I~~C~~;!_t.
<br />
<br />9d, S'fREET AND NUMBER
<br />
<br />1~L6 East Phoenix Ave.
<br />lOa, MARITAL STATUS AT TIME OF DE;ATH 0 Married lJ Never Married
<br />
<br />o ER/Outpatient 0 Decedenl'sHomAssisted
<br />
<br />o [))\ (>>:Other(SpeCllyLLiving
<br />8d. COUNTY OF DEATH
<br />
<br />Hall
<br />
<br />9c. CITY OR TOWN
<br />
<br />6880l
<br />lOb. NAME OF SPOUSE (First, Middle, LaSl, Sulfix) If wile, give maiden name.
<br />
<br />
<br />gl. ZIP CODE
<br />
<br />9g. INSIDE CITY LIMITS
<br />x,x YES 0 NO
<br />
<br />LJ Married, but geparaled jfI Widowed 0 Divorced LJ Unknown
<br />
<br />11. FATHER'S,NAME (First,
<br />Stewart
<br />
<br />Middle,
<br />
<br />Last, Suffix)
<br />Stoulp
<br />
<br />12, MOTHER'S-NAME (Firsl,
<br />Carrie
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />Dahl
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dates of sarvice if yos. 14a.INFORMANT-NAME
<br />(Yes,n181~R,) 6-29-51 6-29-53 Mary Lord
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Sister
<br />
<br />~ Cremation 0 Entombm~mt
<br />
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />FICENSE NO.-. .
<br />
<br />
<br />CITY !TOWN
<br />
<br />16e. DATE (Mo" Dey, Yr.)
<br />September 16, 2006
<br />
<br />15, METHOD OF DISPOSITION
<br />
<br />o Burial
<br />
<br />U Donalion
<br />
<br />16a, EMBALMER-SIGNATURE
<br />Not Embalmed
<br />
<br />STATE
<br />
<br />o Removal I.J Other (Specify)
<br />
<br />Westlawn Memorial Park Crematory
<br />
<br />Grand Island, Nebraska
<br />
<br />
<br />
<br />
<br />17a. FUNERAl. HOME'NAME AND MAILING ADDRESS (Street, Cily orTown, Slale)
<br />A fel Funeral Home, 1123 West Second, Grand Island, NE.
<br />
<br />lB. PART l. Enter the ~ts,--dlseases, injuries, or complicatlons--l~al directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest. or ventricular fibrillation without showing the ellology. DO NOT ABBREVIATE. Enter only one cause on ellne. Add additionallinss if necessary.
<br />IMMEDIATE CAUSE:
<br />
<br />(a) L \AVA C..""-~/
<br />DUE TO, OR AS A CON~~3!!9JCE OF:
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />in de.th)
<br />
<br />on.ellO dealh
<br />
<br />\ \ I\AI)^,~v-:s
<br />
<br />onsello death
<br />
<br />Seqmmtlally list eondltlonsllf
<br />any, leading lathe cause listed
<br />01'1 linea.
<br />Enter the UNDERLYING CAUSE
<br />(dl..... or Injury that initiatod
<br />the events resulting In death)
<br />LAST
<br />
<br />(b)
<br />DUE TO, on AS A CONSEOUENCE OF:
<br />
<br />on,et to death
<br />
<br />(c)
<br />
<br />. .-........-..... .-.,
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />20, IF FEMALE:
<br />
<br />2~ ~NER OF DEATH
<br />)"fl Nalurai I.J Homicide
<br />
<br />21 b, IFTRANSPORTATlON INJURY
<br />o Driver/Operator
<br />
<br />OW" ",,,i.,,,,,,,C"
<br />OR CORONER CONTACTED?
<br />
<br />o YES ~ NO
<br />-...-.-. "..-....
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />16, PART II. OTHER SIGNIFICANT CONDITIONS-Conditions conlribuling 10 the death but not re'Ulting in the underlying cause given in PART I.
<br />
<br />
<br />o Nol pregnant within past yeer
<br />o Pragnanl at lime of death 0 AccidentD Pending Investigation 0 Passenger
<br />
<br />lJ Nol pregnant, but pregnant within 42 days of death 0 Suicide [J Could nol be delermined 0 Pedestrian 21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o NOI pregnanl, b,,1 pregnanl43 days to 1 year bofore death 0 Olher (Specify) COMPLETE CAUSE OF DEATH?
<br />I.J Unknown if pregnanl wilhin Iho pasl year 0 YES 0 NO
<br />
<br />22a. DATE OF INJURY (Mo.. Day, Yr.) 22b, TI~E OF INJUR: J22C.~l.AC~'OF INJURY-At ham., larm, .t'e:I'factorY'-OI~':~buitdl~9' c;';t;;;~I;~~ site, .Ic. (Speclly)
<br />
<br />
<br />22d.INJURY AT WORK? 22e, DESCRIBE HOW INJURY OCCURRED
<br />
<br />I.J YES
<br />
<br />~O
<br />
<br />
<br />I.J YES 0 NO
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYIfOWN
<br />
<br />SlATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo" Day, Yr.)
<br />q ,~ \ to, '" (_"'.JO (0
<br />
<br />24e. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />23h, DATE SIGNED. (Mo" D~YkYr.)
<br />q , \ 10, J-c~". ~
<br />
<br />23c. TIME OF DEATH
<br />-7, '. \ ~\ A. m
<br />
<br />z,..
<br />!'~!!;!
<br />_0:
<br />"tl"'@
<br />U..~
<br />t;;~~t5
<br />!l UJ Z
<br />.8Z=>
<br />,!!1i!8
<br />o ~
<br />00
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To thE! best of my knowledge, death occurred al the lime, date and place
<br />1~due (ot~, c~ure and Tille) 1....
<br />
<br />U,.J....\, \I.) )"A..{^") lJ\ 0
<br />
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the lime, dale and place and duelo the cause(s) staled. (Signature and Tille) '"
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />DYES 0 NO 0 PROBABLY UNKNOWN 0 YES NO NOIAp~~b~e!f 2~~_is NO 0 YES 0 NO
<br />-----nf.i,ij,iE, TlTLti"ANO"iiooR'E'SS OF CERTIFIER (PHYSiCIAN, CORONER'SPHYSICIAN OR COUN Y ATTORNEY) (Type or Print)
<br />Donald Wirth M.D. 2116 W. Faidley Ave., Grand Island, NE. 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />2Sb. DATE FILED BY RE;GISTRAR (Mo" Dey, Yr.)
<br />
<br />~
<br />
<br />SEP J 1 2006
<br />
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