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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 REC~ WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS:KCf/DN,-'WJ:iieHJS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~:i-.:..~.=-.:~:).;il~...-:....~.-...#-:i.?:i:-.'.~..'~.~'
<br />
<br />DATE OF ISSUANCE '-.c~. 'If.. U7rI8'" \ ~ ~
<br />
<br />MAY 2 ~~ Z005 2 0 0 7 0 5 8 2 6 ASS/!~;'_~!fil:: ~:j::J,'n
<br />LINCOLN, NEBRASKA HEAL TfiANiJ_.t'IJJ!~N ~g.~'{..J.i;~:;j}
<br />
<br />-.--
<br />_..::::~;-,....,"':;. -'.'
<br />.~~ ~~:::~;~~f;;~~~"
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT.O''''5 0 ~ 6 4 6
<br />CERTIFICATE OF DEATH Y
<br />
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island. Nebraska
<br />
<br />Sa, AGE-Last Birthday
<br />(Yrs.) 41
<br />
<br />5b. UNDER 1 YEAR
<br />MOS- ']-".DAYS
<br />
<br />
<br />5a, PLACE OF DEATH
<br />
<br />5c, UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />3. DATE OF DEATH (Mo" Day, Yr,)
<br />~pri1 26. 2005
<br />
<br />6, DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />November 22. 1963
<br />
<br />L DECEDENT'S-NAME (Flrsl,
<br />Mary
<br />
<br />Middle,
<br />Christine
<br />
<br />Laat,
<br />McMaster
<br />
<br />Sufi Ix)
<br />
<br />2, SEX
<br />Female
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />506-84-6452
<br />
<br />!:J9.S.PITAL:
<br />
<br />LJ Inpatient
<br />
<br />Q1J:iE8: 0 Nursing Home/LTC [] Hospice Facility
<br />
<br />Bb. FACILITY. NAME (fI nol Insfllulion, give streel and number)
<br />
<br />o ER/Outpatlent
<br />
<br />lO Decedent's Home
<br />
<br />Home:
<br />
<br />303 Church St.
<br />
<br />DOClI
<br />
<br />o .Olhar (Spaclly)
<br />
<br />6c. CITY OR TOWN OF DEATH (Includa Zip Code)
<br />Doniphan
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />
<br />68832
<br />
<br />ad. COUNTY OF DEATH
<br />Hall
<br />
<br />9b. COUNTY
<br />Hall
<br />
<br />90. CITY OR TOWN
<br />Doniphan
<br />ge, APT, NO
<br />
<br />91. ZIP CODE
<br />68832
<br />
<br />5g, INSIDE CITY LIMITS
<br />XI YES U NO
<br />
<br />9d. STREET AND NUMBER
<br />303 Church St.
<br />lOa. MARITAL STATUS ATTIME OF D'EATt:i-iXMarrled Ll Never Married
<br />
<br />1 Ob. NAME OF SPOUSE (First, Middle, Last, Sufllx)" wile, give maiden name,
<br />
<br />LJ Married, bul sepereled LJ Widowed LJ Divorced 0 Unknewn
<br />
<br />Robert McMaster
<br />
<br />11, FATHER'S-NAME (Firsl,
<br />Ronald
<br />
<br />Middle,
<br />
<br />Lasl1
<br />
<br />Pavey
<br />
<br />Suffix)
<br />
<br />12, MOTHER'S-NAME (Firsl,
<br />
<br />._~~!:"]
<br />
<br />Middl.,
<br />Kay
<br />
<br />Malden Surneme)
<br />
<br />Scott
<br />
<br />LJ:'aurlal
<br />
<br />
<br />Robert McMaster
<br />
<br />(/ ----- J6b/~E?J~
<br />
<br />CITY /TOWN
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Husband
<br />
<br />13, EVER IN U,S. ARMED FORCES? Give dales of s.rvice if yes.
<br />(Y.s, no, or unk,) No
<br />15. METHOD OF DISPOSITION
<br />
<br />t:J Donation
<br />
<br />16c, DATE (Mo" Day, Yr, )
<br />April 30. 2005
<br />
<br />LJ Cremetlon LJ Entombmenl
<br />
<br />STATE
<br />
<br />Ll Removal Ll Olher (Sp.cify)
<br />
<br />Westlawn Memorial Park
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />
<br />17., FUNERAL HOME NAME AND MAILING ADDRESS (Slreet. Clly erTown, Slale)
<br />'" Apfel Funeral Home, 1123 West Second, Grand Island, NE
<br />-'
<br />Y"'IWI,.t.t!lI\,"lriMi'~
<br />:!W1.li!J.lfl.>r#'MM
<br />:,;:'~rt: 1B, PART I. Enter the chain of BVBnfsudiseasas, injuries, Or cotnpllcallons--lhal dlreclly caused the death. DO NOT enter terminal events such as cardiac arrest I
<br />i,~::]~::kl resplralory arresl, or ventricular fibrillation wllhout showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />1/~4dti
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />I
<br />I
<br />
<br />I onsello dealh
<br />I
<br />limrediate
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl!ie3Se or condition resulting
<br />In death)
<br />
<br />(a) Asphyxiation
<br />DUE TO, OR AS A CONSEOUENCE OF;
<br />
<br />onsello death
<br />
<br />S.qu.ntlally list conditions, If (b)
<br />any, leading to the c.use lI.ted - DUE TO, ORAS A CONSEOUENCioF:
<br />on line a.
<br />Ent.rth. UNDERLYING CAUSE
<br />(dl..... or Inlury Ihallnlll.l.d (G)
<br />Ihe """nts r.sultlng In d..lh)
<br />LAST
<br />
<br />I
<br />I
<br />I
<br />. ______------L_
<br />I
<br />I
<br />I
<br />I
<br />
<br />onset 10 death
<br />
<br />DUE TO, OR AS A CONSEOUENCE OF;
<br />
<br />onsellc dealh
<br />
<br />(d)
<br />
<br />18, PART If, OTHER SIGNIFICANT CONDITIONS-Condlllon. conlrlbullng Ie Ihe dealh bul nol ,e.ulling In Ihe underlying Gaus. giv.n In PART I.
<br />
<br />19, WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />XX YES 0 NO
<br />
<br />20, IF FEMALE; 21e. MANNER OF DEATH 21b.IFTRANSPORTATION INJURY 21c, WAS AN AUTOPSY PERFORMED?
<br />~ Not pregoonl wllhln pasl year 0 Nalural [] Homicide 0 Dllver/Operalor
<br />Ll Pregnanl alllme 01 dealh 0 AccidenlD Pending Inveslig'lion 0 passeng.r
<br />o Not pregnant, bul pregnanl within 42 days of death muiclde 0 Could nol be d.termin.d 0 P.d.sl,ian 21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Net p,egnant. bul pregnant 43 days 10 1 year before d.alh 0 Other (Specify) COMPLETE CAUSE OF DEATH?
<br />o Unknown if pregnanl wilhln Ihe pasl year ___________ 0 YES XIXl NO
<br />22a. DATE OF INJURY (Mo, Day, Yr) 14:;:tiit1mOW~PLACE OF INJURY-At l1ome, lerm, streel, factorY~Ol\lce bUilding, eOnSlrUGII;;;;-~G (Sp.dfY)
<br />Jlpril 26, 2005 ~ 8: ~pm m I.. At hare
<br />22d INJURY AT WORK? -r2-;DESCRIBE HOW INJURY OCCURRED -
<br />DYES l41I NO I. Mary Christine hung remelf with a oord
<br />
<br />----- --
<br />22f, LOCATION OF INJURY - STREET & NUMBER, APT. NO, CITYIfOWN
<br />3m Olurch Street, Doniphan NE 68832
<br />
<br />LJ YES
<br />
<br />XX NO
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a, DATE OF DEATH (Me" Day, Yr,)
<br />
<br />24a. DATE SIGNED (Mo., Dey, Yr,)
<br />Ma 16, 2005
<br />
<br />24b TIME OF D"ATtf3eL1N\:jtj11
<br />8:5Cpn m
<br />
<br />&
<br />
<br />Z
<br />1;':!!
<br />H,.
<br />'B.%..J
<br />El1.z
<br />8 goo
<br />H
<br />om
<br />...'"
<br /><l
<br />
<br />m
<br />
<br />Hi
<br />;0.- Z
<br />.D!,la:
<br />j~~
<br />U<l~
<br />~~i':i!i
<br />"lUZ
<br />"Z::>
<br />.Doo
<br />~a:O
<br />fh
<br />
<br />24G. PRONOUNCED DEAD (Mo" Dey, Yr.)
<br />Ppril 26, 2CD5
<br />
<br />24d. TIME PRONOUNCED DEAD
<br />8:52 pn m
<br />
<br />23b, DATE SIGNED (Mo., Day, Yr.)
<br />
<br />23c. TIME OF DEATH
<br />
<br />23d. To Ih. best of my knowledge, death occurred allhe lime, dete and piece
<br />end due to Ihe ceuse(s) stated. (Slgnalure and Tille) 'I'
<br />
<br />24e. On the basis 01 examina.tion and/or Investigation I In my opinion death occurred at
<br />the lime, dale and place and due to the cause(s) staled. (Signature and Tille) T
<br />
<br />25, DID T08ACCO USE CONTRIBUTETO THE DEATH?
<br />
<br />
<br />
<br />o YES ~ NO 0 PROBABLY 0 UNKNOWN 0 YES ~ NO
<br />27, NAME, TITLE AND ADDRESS OF CERTiFIER iPHysiciAN, -CORONER'SP-HYSICIAN OR COUNTY AnORNEYY(T~-.-o-;:Prlnl)
<br />k J. YOIJlg, Hall County Attorney I 231 South Locust Street, L-iI'8nd Island,
<br />
<br />
<br />Au
<br />
<br />NOI AppliGabl. il 2~~.~~.? ... 0 YES 0 NO
<br />
<br />NE
<br />
<br />68801
<br />
<br />280, REGISTRAR'S SIGNATURE
<br />
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />MAY 1 9 2005
<br />
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