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<br />STATE OF NEBRASKA
<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 RE(;f!flDGNc.8!..E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTlWSIreT-lON-..ylHiC):! IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~. O;.'.";":"~"-1- i~. '.O:~~'-~'.;~~
<br />
<br />DATE OF ISSUANCE ~.= - -f). ~=7_-~
<br />MAR 222007 20070' '3867 :1'~ ~~.t;OQp~Ff~
<br />ASS/ST~i-!T'sTA7t"REGfStflARI
<br />LINCOLN, NEBRASKA HEALtHAND H1JMAN SERYIl!Eii
<br />
<br />0 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FIN~CE ~.!\NUS~~.'::?_.i'8 0 8
<br /> CERTIFICATE OF DEATH." -'''-,., -,. .,-.
<br /> 1. DECEDENT'S.NAME (Firsl, Middle, Last, SuffiX) t SEX .,,- "".:- ~~#nF DEATH (Mo.. Day, Yr.)
<br /> \ Roy Daryl King Male March 11, 2007
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE.L.st Birthday 5b. UNDER 1 YEAA 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo.. Day, Yr.)
<br /> (Yr..) MOS, I DAYS HOURS I MINS.
<br /> Horace, Nebraska 84 May 3, 1922
<br /> 7, SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />'\ 508-18-5829 ~: til Inpallenl llIIilll: U Nursing Home/LTC o Ho.plce Facility
<br /> '~ 8b. FACILlTY.NAME (II not Instllutlon. glv~ slreet and number) o ER/Outp.llent o Decedenl's Home
<br /> ~ Saint Francis Medical Center UCD'I o Other(Spacify)_____
<br /> a:
<br /> 15 8c. CITY OR TOWN OF DEATH (Include Zip Code) I ed. COUNTY OF DEATH
<br /> ...J
<br /> 0( Grand Islan'd 68803
<br /> a: Hall
<br /> !l1 ea. RESIDENCE.STATE jOb.COUNTY lec.CITYORTOWN
<br /> ~
<br /> j Nebraska Hall Grand Island
<br /> " ed. STREET AND NUMBER I ee, APT. NO 191. ZIP CODE I 9g.INSIDE CITY LIMITS
<br /> ,2
<br /> 'E 3990 W. Capital Ave. 106 68803 Ij YES 0 NO
<br /> , lOa. MARITAL STATUS AT TIME OF DEATH iii Married 0 Never Married lOb. NAME OF SPOUSE (First. Middle, Laet, Suffix) If Wife, glv, maiden name.
<br /> is. o Marned. bul separated 0 Widowed o Divorced 0 Unknown
<br /> E Arlene Liebsack
<br /> 8
<br /> &l 11, FATHER'S-NAME (Flr.t, Middle, Lasl, Sulllx) T2. MOTHER'S-NAME (First, Middle, M.ld.n Surname)
<br /> {l Albert Roy King Agnes Tuma
<br /> 13. EVER IN U.S. ARMED FORCES? Glv. date. 01 service lIyes.!14a.INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yes, no, orunk.) Yes 12/02/1942-09/27/1945 Arlene King Wife
<br /> 15, METHOD OF DISPOSITION IS'n;;;'IJ/j) m#Az \ 11Sb. LICENSE NO. ISc. DATE (MO.. D.y, Yr,)
<br /> Illl Burial o Donation 1071 Mal'ch 14, 2007
<br /> o Cram.Uon o Enlombment Hid. CEMETERY, CREMATORY OR OTHER LOCATlbN CITY /TOWN STATE
<br /> o Removal o Olher (Speclly)
<br /> Grand Island City Cemetery Grand Island Nebraska
<br /> 17.. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clly orToWn, SI.te~ l17b. Zip Code
<br /> All Faiths Funeral Home. 2929 S. Locust Street, Grand Island, ebraska 68801
<br /> CAUSE OF DEATH (!ee instructions and examples)
<br /> le. PART I. Enter lh. chain 01 events..dl.eases, Injurlel, or compllc.tlon...thal directly cau.ed the dealh, DO NOT enter lermlnalevent. .uch as cardl.c arrest, APPROXIMATE INTERVAL
<br /> I
<br /> respiratory arre.t. or venlrlcular flbrlll.tlon wllhoul Showing the etiology, DO NOT ABBREVIATE. Enter only on. cauee on a line. Add .ddIUon.lllnes II n.cessary. I
<br /> IMMEDIATE CAUSE: I onsal 10 dealh
<br /> (I J'/l/~d //l4CtA~ ~.tH-, I (U/.te.)u
<br /> (.) I
<br /> IMMEDIATE CA USE (Filal
<br /> dl..... Ill' c<ll1dUlonruuftlng DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br /> il 4e.lI1) I
<br /> (b) I
<br /> Sequenllelfy list .ondlllone, II I
<br /> eny, le.dlng to II1tc.u.. lI.tod DUE TO, OR AS A CONSEQUENCE OF; I onl.tto death
<br /> on IIn... I
<br /> Enlor 1110 UNDERLYING CAU9E I
<br /> (dl..... or Injury Ihe' Inltl.led (c)
<br /> lI1e evonts rnulllng In 4e.lI1) DUE TO, OR AS A CONSEQUENOE OF: I onoet 10 dealh
<br /> lASf I
<br /> (d) I
<br /> 18. PART II. OTHER SIGNIFICANT CONDITIONS.Condlllons contnbutlng 10 the death but not resulllng in Ihe underlying cause given In PART I. 19. WAS MEDIOALEXAMINER
<br /> OR OORONER CONTAOTED?
<br /> DYES o NO
<br /> a: 20, IF FEMALE: 21.. ~NER OF DEATH 21b, IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PE~FORMED?
<br /> W
<br /> ~ o Nol pregn.nt wllhln p.st ye.r ' Natural 0 Homlcid. o Drlver/Operalor /
<br /> DYES ~o
<br /> D Pr.gn.nt at time of death o AcoldentD Pending Investlg.tlon o paseenger
<br /> I.l U Pedesli1.n
<br /> j o Nol pregn.nt, but pragnanlwllhln 42 days of de.th o Sulcld. 0 Could not b. determined 21d. WERE AUTOPSYFINDIN(lS AVAILABLE TO
<br /> ~ o Not pregnanl, but pregnant 43 daYl 10 1 year before dealh o Other (SpeCify) COMPLETE CAUSE OF.DEATH?
<br /> li o Unknown II pragnant wllhln the past year CJ YES ~O
<br /> is. ~--~.~--
<br /> e
<br /> 8 22a. DATE OF INJURY (Mo" D.y, Yr.) I 22b. TIME OF INJUR: 122.. PLACE OF INJURY.At home, farm, streel, I.ctory, olllce building, conelructlon slle, etc, (Speclly)
<br /> &l
<br /> {l 22d.INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br /> DYES [J NO
<br /> 221, LOOATION OF INJURY. STREET & NUMBER, APT. NO. CITYITOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo.. D.y, vr) ~~~ 24.. DATE SIGNED (Mo" Day, Yr.) 24b. TIME OF DEATH
<br /> ~~ March 11. 2007 m
<br /> i~ 23b. DATE SIGNED (Mo., Day, Yr,) I 23c. TIME OF DEATH iiii:!j 24c. PRONOUNCED DEAD (Mo.. D.y, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> tl~ i~~~
<br /> c.::J:~ March 14, 2007 09:00 A.m m
<br /> EQ.Z E"')-Z
<br /> 8 g>o 23d. To the best otfnv 1Ie~.th occurred 'I the time, d.le and plac. affi!ZO 24e. On the basis 01 ...mlnatlon and/orlnv'sllgatlon, In my opiniOn de.th oocurred at
<br />,J 1l'g CDz:::l
<br />and duo 10 I a cau: .(~stal '. (Slgnalure .nd Tllla)" "'00 the lima, d.te .nd place .nd due 10 the ceuse(o) slated. (Slgn.ture and Tltla),.
<br />~S ,'aa:O
<br /> .\ :( ';//... 'J/ 8 "
<br />"-")
<br />"J 25. DID TOBACCO ~27:TR)BUTE TO THE'bEATH? 126a. HAS ORGAN OR TISSUE ~ONATION BEEN CONSIDERED? I 26b. WAS CONSENT GRANTED?
<br /> U YES Q. 0 /6 PROBABLY 0 UNKNOWN o YES Ii!' NO Not Appllc.ble" 26a Is NO ~YES o NO
<br /> 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (T'yP' orPnnl)
<br /> John A. Wagoner,M.D., 800 Alpha st. , G,Fand Island, Nebraska 68803
<br /> 28. REGISTRAR'S SIGNATURE ,MM I~;j, J. f~" 2eb. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> p vvv1- ... MAR I ., 2007
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