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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 FlL6 WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS ~H;CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~~.~'2=":c.o."'.J.~~~ /p.~~'_:.:.~=-.~"~f~~-.'._._~,
<br />
<br />DATE OF ISSUANCE - - .ti~~~-
<br />20070666 4 ff~~ tANLEY$tc~~
<br />JUN 2 0 Z007 AS$IStAN~_~Jf!G/~Afl
<br />LINCOLN, NEBRASKA HEA1/ij~riDffljMA}JSERVjt~
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANC~AND S\,JPc~
<br />CERTIFICATE OF DEATH
<br />
<br />
<br />~~e ~F:p~lMO.. Day, Yr,)
<br />Mityit'2007
<br />
<br />6. DATE OF BIRTH (1.40.. Day. Yr,)
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />2.SEX
<br />
<br />Male
<br />
<br />5c. UNDER 1 DAY
<br />HOURS 1.4 INS.
<br />
<br />Sa. AGE.Last Birthday 5b. UNDER 1 YEAR
<br />(YrB.) MOS. DAYS
<br />
<br />49
<br />
<br />ea. PLACE OF DEATH
<br />
<br />December 15, 1957
<br />
<br />027-48-9800
<br />8b. FACILITY-NAME (II not Institution, giv~ stre~t and number)
<br />
<br />~:
<br />
<br />o Inpatient
<br />
<br />QIIJE!!: 0 Nursing HomeltTC 0 Hospice Facility
<br />
<br />I
<br />I
<br />i2
<br />i
<br />I
<br />~
<br />II
<br />{!.
<br />
<br />~ ERIOulplbent
<br />
<br />o Decedenr. Home
<br />
<br />Saint Francis Medical Center
<br />
<br />ec. CITY OR TOWN OF DEATH (Include Zip Coda)
<br />
<br />Grand Island 68803
<br />91, RESIDENCE.sTATE
<br />
<br />Nebraska
<br />ed. STREET AND NUMBER
<br />
<br />2540 Ja Street
<br />10.. MARITAL STATUS AT TIME OF DEATH fiI Merrled 0 Never Married
<br />
<br />o roo. 0 Olher(Speclty)
<br />ed. COUNTY OF DEATH
<br />
<br />68801
<br />lOb. NAME OF SPOUSE (First. Middle, Laet, Suffix) II wile, give maiden name,
<br />
<br />
<br />Hall
<br />
<br />lib. COUNTY
<br />
<br />Hall
<br />
<br />al. ZI P CODE
<br />
<br />aa.INSIDE CITY LIMITS
<br />
<br />Ij YES 0 NO
<br />
<br />o Mamed, but separated 0 Widowed 0 DIVorced 0 Unknown
<br />
<br />o Cremallon 0 Entombment
<br />
<br />
<br />,.
<br />t6d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />14b. RELATIONSHIP TO OECEDENT
<br />
<br />Wife
<br />t6C. DATE (1.40.. Day, Yr. )
<br />Ma 25,4006- 2007
<br />STATE
<br />
<br />11. FATHER'S.NAME (First,
<br />Robert Parsons
<br />13. EVER IN U.S. ARMED FORCES? Giva dates or service II yes.
<br />
<br />Middle,
<br />
<br />Last.
<br />
<br />(First,
<br />Hawkins
<br />
<br />Middle,
<br />
<br />Malden Surnamo)
<br />
<br />(Yes, no. or unk,) No
<br />15. METHOD OF DISPOSITION
<br />ell Burial 0 OonaUon
<br />
<br />o Removal 0 Other (Spemty)
<br />
<br />Grand Island City Cemetery
<br />
<br />17a. FUNERAL HOME NAME ANO MAILING ADDRESS (Street, Clly or Town, State).
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />
<br />l,;
<br />
<br />
<br />ATH (See Instruct ons and examp n}
<br />
<br />lB. PART I. Enter the chain 01 evenls--dlseases, InJuries, or compllcallons..thal dlreclly caused the death. 00 NOT enter teonlnal evenls such as cardiac arresl.
<br />respiratory arrest. orven~lcular flbrllleUon wllhout snowing the ellology. DO NOT ABBREVIATE. Enler only one ceuse on a line. Add addlUonalllnesll necessery,
<br />IMMEDIATE CAUSE:
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />on.olto doath
<br />
<br />IMMEDIATE CAUSE (FNI
<br />dll_ 01' cOl'1dllon relURlng
<br />hdealh)
<br />
<br />(s) cardiac arrest
<br />DUE TO, OR AS A CONSEqUeNCE OF:
<br />
<br />immediate
<br />onset to death
<br />
<br />Sequentlllly Iltl conditions, .
<br />""Y, _1"Il III I1Ic_ Oiled
<br />01'11111I1.
<br />EnI&r lit UNDERLYtlG CAUSE
<br />(dlolOlI or Injury that Inltlltld
<br />1110 ovenll nllUllI1g In d....)
<br />ursr
<br />
<br />~ h ertensive & coronar
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />
<br />heart disease
<br />
<br />unknown
<br />onset to death
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF;
<br />
<br />onset 10 death
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions cOnlrlbullng to lhe death bul not resulting In Ihe underlying cause given In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />n YES 0 NO
<br />
<br />a:
<br />II!
<br />~
<br />w
<br />()
<br />j
<br />l
<br />e
<br />B
<br />ill
<br />{!.
<br />
<br />20. IF FEMALE:
<br />o Nol pregnant within pasl year
<br />o Pregnenl atUme of deelh
<br />o Not pregnant. but pregnant wllnln 42 days of death
<br />o Notpregnsnl, but pregnsnl 43 days to 1 yearbeloredeath
<br />Q Unknown II pregnanfwlthln the pesl year
<br />
<br />21e,MANNER OF DEATH
<br />I:ii2 Natural 0 Homicide
<br />
<br />o AccidentD Pending Invesllgatlon
<br />
<br />o Sulcldo 0 Could not bo dotennlned
<br />
<br />2t b, IF TRANSPORTATION INJURY
<br />o Drtver/Operalor
<br />
<br />o Passenger
<br />
<br />o Pedestrlen
<br />
<br />o Other (Speclly)
<br />
<br />210, WAS AN AUTOPSY PERFORMED?
<br />
<br />'t1 YES 0 NO
<br />
<br />2td. WERE AUTOPSY ANDIN<.iS "YAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />~ YES 0 NO
<br />
<br />22a. DATE OF INJURY (1,10" DIY, Yr.)
<br />
<br />22b. TIME OF INJURY 220. PLACE OF INJURY.AI home, fann, streel, feotory. olncl building, oonstruotlon silo, oto. (Specify)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />
<br />DYES 0 NO
<br />
<br />221, LOCATION OF INJURY - STREET & NUMBER, APT, NO.
<br />
<br />ClTYfTOWN
<br />
<br />SlATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo.. Day, Yr.)
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24~. TIME OF DEATH
<br />
<br />1i'~
<br />i~
<br />l~~
<br />~~i!i
<br />1'6
<br />i
<br />~i
<br />
<br />m
<br />
<br />>-~ ~
<br />"!'!"
<br />:B~ 0
<br />!il:~~
<br />~'.l:z
<br />"ffizO
<br />ez:;;>
<br />~~8
<br />8~
<br />
<br />
<br />m
<br />
<br />23~, DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />23C. 11 ME OF DEATH
<br />
<br />23d, To the beBt of my knOWledge, death occurred at lheUme, date and place
<br />and duo to the cause(s) .taled. (Signature and TIlle) T
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />26a. HAS ORGAN OR TISSUE DONATI
<br />
<br />DYES JO(NO Q PROBABLY 0 UNKNOWN 0 YES xijI NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Pont)
<br />
<br />L nelle D. H
<br />
<br />Not Applicable if 2Ba Is NO 0 YES 0 NO
<br />
<br />
<br />
<br />28b. DATEJU~t :t&ST200't. Day, Yr.)
<br />
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