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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 REC~DN FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST,4TISnCS SEcr/BAt. WHICH IS
<br />
<br />:~::~::::::;TORY FOR Y"A" RECOROS l M..k i~
<br />FES 06 200? "-, S~':4fAr-iiy"ix}6oPER
<br />2 0 0 7 0 12 6 ~ .. ... As:sisTA'!i~~fiiiEl~ftG!$TRAR
<br />- .;HEAf..r~~t{t!fJj'/1AAN S~1l VICES
<br />.",'~,. ..'~':,::;~-~
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />\
<br />
<br />"=:;',
<br />'"',
<br />
<br />
<br />.5.. TA. TE OF NEBRASKA-. .0.. EPARTMENT OF HEALT. HAND HU.MAN SERVICES FINA. NCE AND SUPPORb C3 · 322 .0.
<br />._____~~lnIFICATE OF DEATH ,__ _ ..~ '., ..' -
<br />
<br />1. DECEDENT'S-NAME (First, Middle, Last, Sufllx) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Marion Katherine Williams Female December 2, 2006
<br />
<br />· ,,;, ~": =:; o~;~::;: o~ :;:::~'~oc "'~" r ~~:,"; ;''""'~ "':~J"::'. ::5::: ~ :'~~o. ;':m 1';~;" '"
<br />
<br />
<br />7. SOCIAL SECURITY NUMBER ea. PLACE OF DEATH
<br />507-12-6021 iiOSfflA1.. Xl in".:i.n: Q1HEB; D Nursing Homo/LTC DHospic.Fscillty
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<br />FACILITY-NAME (II not instllutlon, give stroel and number)
<br />
<br />I:l ER/Oulpallent
<br />
<br />D Decedont's Home
<br />
<br />St. Francis Medical Center
<br />
<br />D to\ D Othor(Speclly)___
<br />
<br />eCCITY~;~~~OF;~Al~~~UdOZiP~-" 6880;--l6d.COUNTYf::riH --.---
<br />9aRESI;:~;:T~ka --~OU~:ll--LO;;;~d Islan;---------
<br />
<br />9d. STREET AND NUMBeR -- - - - ---~ge -APT NO 9f liP CODE ~NSIDE CITY LIMITS
<br />1812 N. Grand Island Ave. ~ 68803 ~ YES D NO
<br />-. 1 Da. MARITAL STATUS ATTIME OF DEATH D Msrrled I.] Neve, Ma"'Or1 Db. NAME OF SPOUSE (Flfst, Mlddlo, Lasl, SUltl') II wile, glvo maiden ~ - -
<br />
<br />D Marrlod, but separatod q(Wldowod 0 Divorced I.] Unknown
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<br />- --------~----~
<br />Last, Suflix) 12. MOTHER'S-NAME (Firsl, Middle, Maiden Surname)
<br />Hayes Helen I. Bole
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<br />t I. FATHER'S-NAME (Firsl,
<br />Charles
<br />
<br />Middle,
<br />
<br />F.
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<br />13. EVER IN U.S. ARMED FORCES? Glvo dal.s 01 service il y... 14a. INFORMANT-NAME
<br />(Ye5,no,orunk) No Evelyn Desch
<br />
<br />15'~::~a~OFDI~~:~:;:~- 16aEM8ALM~, _ -- J:LICENSENO'~~~S- _
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<br />D Cremation D Enlombmonl -16d. Ce~ETERY, CReMAT-ORY DR O~~ CITY I TOWN
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<br />14b. RELATIONSHIP TO DECEDENT
<br />Sister
<br />
<br />16c DATE (Mo., Day, Yr.)
<br />ecember 6, 2006
<br />
<br />STATE
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<br />D Romoval I:l Olhor (Specily)
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<br />Grand Island Cemetery,
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<br />Grand Island, Nebraska
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<br />170. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City o<Town, Stalo)
<br />Apfel Funeral lIome, 1123 West Second,
<br />, r~
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<br />PART l. Enler the Qh~~~--dlseasas, injuries, or complicallons--that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />resplralory arre51, or vonlricular Itbrlllation without showing the eliology. DO NOT ABBREVIATE. Enler only one causo on a line. Add addltlonollln.s if necessary.
<br />
<br />IMMEDIATE CAUSE: L
<br />
<br />IMMEOIATECAUSE(Flnal(a). t..~ "-->~
<br />dlsoaseorcondltlon resulting DUE TO, ORA~AC~eNCE OF:
<br />In death)
<br />
<br />Sequentlalty IIslcondltlon., if (b) ..' . \i\~~
<br />.ny, leading to the cause IIst.d ----ouE- TO,OR AS A Go~CE C;p--
<br />on line 8.
<br />Enter the UNDERLYING CAUSE
<br />(dl....e or Injury Ih.tlnitleted (c)
<br />the events resulting In death)
<br />LA>T
<br />
<br />
<br />\J I ~
<br />~,_._-_._.
<br />.~~
<br />-- ---=- -----
<br />tW-=-~
<br />
<br />I
<br />I
<br />
<br />I onsettOdoah-
<br />-~~. -
<br />
<br />: onset to deeth
<br />
<br />I I\.., 2 w'
<br />~."._.,
<br />I on,ello dealh
<br />I
<br />
<br />I ! \) L
<br />--~-~~-
<br />I onset to deaH~
<br />I
<br />I
<br />
<br />c..
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF;
<br />
<br />(d)
<br />
<br />20. IF FEMALE:
<br />~Ol pregnant within past year
<br />lJ Prognanl at lime 01 death
<br />U Nol prognarH, bul prognant within 42 day' 01 doalh
<br />U Not pregnant, but pregnant 43 days 10 1 year belore dealh
<br />o Unknown if pregnant within the past ya<1r
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<br />21a. MANNER OF DEATH
<br />j(Natural D Homicide
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<br />D AooldonlD Pending Invostigatlon
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<br />~--- - --
<br />19 WAS MeDICAL EXAMINER
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<br />OR CORONeR CONTACTED?
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<br />o YES ,t/- NO
<br />___ _JDC_~_
<br />21 b. IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />D Driv.r/Operator
<br />
<br />D passong.r
<br />
<br />D Pedestrian
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<br />U YES
<br />
<br />)iNO
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<br />lB. PART II OTHER SIGNIFICANT CONDITIONS-Conditions conlrlbutlng 10 tho death bUI nol resulllng In .ho underlying cause given In PART I.
<br />
<br />~~
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<br />D Suicid. D Could nol b. detsrmlnod
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<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
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<br />D D.h.r (Specify)
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<br />COMPLETE CAUSE OF DEATH?
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<br />22e. DATE OF INJURY (Mo., Day, Yr.)
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<br />22b. TIME OF INJURY
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<br />__. , "".. _~_~~~XNO-
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<br />22c. PLACE OF INJURY-At home, I.rm, streel, t.ctory, otlle. building, construction slle, ote, (Specify)
<br />
<br />n1
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<br />22dINJURY AT WORK? }2. DESCRIBE HOW INJURY OCCURRED -
<br />DYES D NO
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<br />22f. LOCATiON OF INJURY. STREET & NUMBER, APT NO. CITYlfOWN
<br />
<br />STATE
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<br />liP CODE
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<br />23s. DATE OF DeATH (Mo" Doy, Yr.)
<br />DECEMBER 2, 2006
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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 />23c. TIME OF DEATH
<br />19:36 pm
<br />
<br />Z>"
<br />..W
<br />$'UZ
<br />liUlgj
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<br />Q. a.. C,( :::J
<br />E "'" i: :1:
<br />SffizO
<br />~z=>
<br />.coo
<br />~a:O
<br />815
<br />
<br />m
<br />
<br />-- ----,- -",-"",-,"'-
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<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />DECEMBER 5, 2006.
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<br />24c. PRONOUNC~D DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
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<br />23d. To the best of my knowledge, death occurred at the time! date and place
<br />and due 10 tl10 cause(s) slsled. (Si nalllre and Title) T
<br />
<br />WJ-
<br />
<br />248. On Ihe basis of examination end/or investigation, in my opinion death occurred al
<br />tho time, dale and pl,ce and due 10 tho cause(s) stalod. (Signaluro and Tille) T
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<br />25. DID TOBACCO USE CONTRIBUTE TOTHE DEATH' 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />
<br />o YES ~ NO D PROBABLY D UNKNOWN DYeS CkNo _ Not Applicsble 1126a ~.N9~~8 D NO
<br />-2ijoJAME, TrrGAND ADDRESS OF CERTiFIER- (PHYSiciAN, CORONER'S PHYSICIAN ORCOuN?YA~Yi- (TYpe or Prlnl)"-
<br />W. J. Landis M.D. 2444 W. Faidley Ave., Grand Island, NE. 68803
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<br />2Bs. REGISTRAR'S SIGNATURE
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<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo., Dey, Yr.)
<br />
<br />~I
<br />
<br />DEe
<br />
<br />7 2006
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