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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 RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION,-WH!CH IS
<br />
<br />:~:~::~::;RY FOR YTTAL RECORDS ~~Er:!:oifi;\
<br />
<br />APR 1 8 Z007 ASSISTANT STAre REGISTRAFt ._
<br />LINCOLN, NEBRASKA 200705895 HEALTtMNQ ~UivrAN's'ERoj/(:iES
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE..J\NCl SUf>PURT
<br />CERTIFICATE OF DEATH ----~-:.--O-L2_422_1_
<br />
<br />1. DECEDENT'S.NAME' (Firsl, Middle,
<br />
<br />Habel Lily
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Lasl,
<br />Green
<br />
<br />Suffix)
<br />
<br />2. SEX
<br />
<br />X_gnale
<br />5e. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />3. DATE OF DEATH (Mo" Day, Yr.)
<br />
<br />
<br />5a. AGe.last Birthday 5b. UNDER 1 YEAR
<br />(Yr..) MOS. DAYS
<br />93
<br />
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />Mason City, Nebraska
<br />
<br />July 17, 1913
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />6a. PLACE OF DEATH
<br />
<br />507-54-7300
<br />
<br />o Inpollonl
<br />
<br />Qlliffi: ~ Nursing Home/lTC U Hospice Facility
<br />
<br />H.9..sem.i:
<br />
<br />8b. FACILITY. NAME (If liot institution, give ~Ire[)t and number)
<br />Grand Island Veterans Hone
<br />
<br />2300 Hest Capital Avenue
<br />
<br />8e. CITY OR TOWN OF DEATH (Includo Zip Code)
<br />Grand Island, Nebraska 68803
<br />
<br />90RE~D~~;::~~-'- L_COUNTY~.all
<br />
<br />9d. STREE'T AND NUMBER
<br />
<br />U ER/Outpetlenl
<br />
<br />o Decedent's Home
<br />
<br />OM
<br />
<br />o Olher (Specify)
<br />
<br />8d. COUNTY OF DEATH
<br />Hall COUI1ty
<br />
<br />gc. CITY OR TOWN
<br />Grand Island
<br />
<br />T9;APTNO---T;:Z[;~~ 1
<br />
<br />
<br />lOb. NAME OF SPOUSE (Flrsl, Middle, lesl, Sulllx) If wife, give maiden name.
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />Xl YES 0 NO
<br />
<br />522__W~.:?t~9th St.
<br />
<br />lOa. MARITAL STATUS ATTIME OF DEATH ~ Married 0 Nover Married
<br />
<br />
<br />o Married, bUI separaled U Widowed 0 Divorced 0 Unknown
<br />
<br />Glen Green
<br />
<br />11. FATHER'S.NAME (First,
<br />Levi
<br />
<br />Middle,
<br />
<br />lasl, Suflix)
<br />Patrick
<br />
<br />12. MOTHER'S-NAME (Flrsl,
<br />Hattie
<br />
<br />Middle,
<br />Jane
<br />
<br />Maiden Surname)
<br />English
<br />
<br />13. EVER IN U.S. ARMED FORCES? Glvo dates 01 service if yes. 14a.INFORMANT.NAME
<br />(Yes,no,orunk.) No Thomas Donahue
<br />
<br />14b. RELATIONSHIP TO DECeDeNT
<br />
<br />Son
<br />
<br />I=SE:~~!~F
<br />
<br />CITY /TOWN
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />16aEMB:lMER.SIGNAT~ ~ . ~
<br />
<br />
<br />16d. CEMETERY, CRE'MATO-RY O-R mLATION
<br />
<br />16c. DATE (Mo.. Dey, Yr. )
<br />April 13. 2004
<br />
<br />~Burlel
<br />
<br />o Donation
<br />
<br />U Cremallon 0 Enlombmenl
<br />
<br />STATE
<br />
<br />U Removal 0 Other (Specify)
<br />
<br />Douglas Grove Cemetery,
<br />
<br />Comstock. Nebraska
<br />
<br />- ...
<br />......-----
<br />170. FUNERAL HOME NAME AND MAILING ADDRESS (Streal, Clly orTown, Slela)
<br />Apfel Funeral Home, 1123 West Second, Grand Island, NE
<br />
<br />
<br />
<br />i r
<br />APPROXIMATE INTERVAL
<br />
<br />18, PART I. Enter the r.hAln 01 AVAr1t~--diseBSe.s1 injuries! or complications.-Ihat directly caused Ihe death. DO NOT enter terminal events such as cardiac arrest,
<br />resplralory arresl, or ventrlculer IIbrlllatlon wilhOUI showing the etiology. DO NOT ABBREVIATE. Enler only one causa on a line. Add addllionolllnes If nocessary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onsel to death
<br />
<br />IMM~DIA TE CAUSE (Final
<br />disease or condition resulting
<br />In death)
<br />
<br />(a) Stage 3 DEl!!l~Dtia _
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />> 1 Year
<br />onsello death
<br />
<br />
<br />Sequenllally II., oondlllon., If (b)
<br />any, leading to the ceuselisted Du~'TO,OR AS A CONSEQUENCE OF:
<br />on linell.
<br />Ente, the UNDERLYING CAUSE
<br />(disease or Injury Ihellnltlaled (e)
<br />theeventsrosulllng In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />lA'rr
<br />
<br />onsel to dealh
<br />
<br />oneello dealh
<br />
<br />(d)
<br />
<br />18. PART II. OTHeR SIGNIFICANT CONDITIONS-Condlllons conlrlbullngto Ihe dealh but not resulting in the underlying cause given in PART I.
<br />Cachexia with Malnutrition, An6Tlia.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES
<br />
<br />~ NO
<br />
<br />..~
<br />:r
<br />G)'I'
<br />ta
<br />E
<br />o
<br />
<br />20. IF FEMAlE:
<br />U Not pregnanl wllhln past year
<br />o Pregnant alllme 01 death
<br />U Nol pregnanl, bUI pregnant within 42 days 01 dealh
<br />o Not pregnant, but pregnanl43 days 10 1 yea.r before death
<br />o Unknown II pregnant wllhin the pasl year
<br />
<br />210.MANN.ROF DeATH
<br />lii1 Natural U Homicide
<br />
<br />210. WAS AN AUTOPSY PERFORMED?
<br />
<br />21 b.IF TRANSPORTATION INJURY
<br />o Drlver/Opsealor
<br />
<br />o Pessenger
<br />
<br />o Pedeslrlen
<br />
<br />o Other (Specify)
<br />
<br />o AccidentD Pending Investigatlon
<br />
<br />DYES :!? NO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAilABLE TO
<br />COMPLeTe CAUSe OF DEATH?
<br />DYES U NO
<br />
<br />o Suicide 0 Could not be determined
<br />
<br />~!;0l'-lN= jr~..-O"l\-'i<.~. _
<br />
<br />22b. TIME OfJfHUBY. .l.2L1'~A_Ce OF INJURY.AI home, farm-,-~~~~_I~t.~ry, .offlce building, construction site, etc. (Specify)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />220. DESCRIBe HOW INJURY OCCURRED
<br />
<br />iJ YES 0 NO
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />AprJ-~__lO, 2Q.o7
<br />
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />April 10, 2007
<br />
<br />24e. DATE SIGNED (Mo" Dey, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />Z)-
<br />>-5 ~
<br />~!:la:
<br />iH
<br />Q.a.. oC( ~
<br />Ht~
<br />"IIJ Z
<br />1l~8
<br />~c:u
<br />815
<br />
<br />m
<br />
<br />230. TIME OF DEATH
<br />7:20 A.
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To Ihe best 01 my knowledge, deelh occurred allhe lime, dela end place
<br />and d~el~,~~.. causO(S),T:1SI9neIUre end Tille) T
<br />
<br />? 11\ I' 'r.- I},) i/IO .. I
<br />
<br />248. On the basis of examination and/or investigation, in my opinion doath occurred at
<br />Ihe time, dele end place end due to Ihe causa(s) "eted. (Slgoslure and Title) T
<br />
<br />25. DID TOBACCO USE CONTRIOU' TO THE DEATH?
<br />
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />RGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />o yeS ~_~O__ U PROBABlY g UNKNOWN _ U yeS. . III NO NOI Applle_a_~I~~_6! l_s~~__9 YE~__g_N.?__.___
<br />27. NAME, TITLE AND ADDRESS OF CEnTIFleR (PHYSICIAN, CORONeR'S PHYSICIANORCOUNTY ATTORNEVj-(Type or Print)
<br />M.A. Torrpkins, M.D., Grand Island Veterans Home, Grand Island, I\'E 68803
<br />
<br />28.. REGISTnAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FilED BY REGAP~R to.~aY'~007
<br />
<br />4td1f.~
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