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<br />
<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 $TATIS~~f'1~HICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS..~. ".'~. .~. ~.~~I. ~~. =.._:'..'--.'~'
<br />
<br />DATE OF ISSUANCE "ff!al,o. .' -~'Si.
<br />
<br />
<br />L1~~O:N~ N~B;~~~ 200707345 ~;:~w~
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC~i!:!~. ..,~.AN. '. '.~. - 7 2 853 4
<br />. '. CE.RTIFICATE OF DEATH--=':::~-~. U
<br />
<br />
<br />DECEDENT'S-NAME (Firsl,
<br />Glen
<br />
<br />Middle,
<br />(NMI)
<br />
<br />Last,
<br />Hinkle
<br />
<br />Suffl.)
<br />Jr.
<br />
<br />2, SEX
<br />Male
<br />
<br />Palmer, Nebraska
<br />
<br />5a, AGE-Last Birthday 5b. UNDER 1 YEAR
<br />(Yrs.) MOS DAYS
<br />
<br />63
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />3, DATE OF DEATH (Mo.. Day, Yr.)
<br />July I}, 2007
<br />
<br />6. DATE OF BIRTH (Mo., Day, Yr,)
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />November 12, 1943
<br />
<br />8a. PLACE OF DEATH
<br />
<br />JiQ.S..elJAJ. :
<br />
<br />o Inpalient
<br />
<br />QJJiIifl; 0 Nursing Homa/LTC [J Hospice Facility
<br />
<br />(If not institution, gIve street and number)
<br />
<br />U ER/Oulpallanl
<br />
<br />01 DaCadant's Home
<br />
<br />Street
<br />10~:MI\RITAL STATUS ATTIME OF DEATH iMarrlad [J Never Marrlad
<br />
<br />[J 0Cl'\ [J Olher (Spacify)
<br />"_~YOF"DEATH
<br />
<br />
<br />9c. CITY OR TOWN
<br />Grand Island
<br />
<br />-~O 8f.~~~0;;
<br />
<br />lOb. NAME OF SPOUSE (FlrSI, Mlddla, Last, Sulli.) If wife, giva maiden nama.
<br />
<br />I~ INSIDE CITY LIMITS....
<br />
<br />lX YES 0 NO
<br />
<br />Dee Anna Conrad
<br />11, FATHER'S-NAME (Firsl, Middle, Last, SUlfi;~~R'S-NAM. E (Flr'l,
<br />Glen H. Hinkle _L Mabel
<br />13. EVER IN U.S. ARMED FORCES? Give dates of .ervice if yes, 14a, INFORMANT-NAME
<br />(Yes,no,orunk.) no Dee Hinkle
<br />
<br />15'~:r~e~OFDI~~:~::i~~ 16a_~MBALMER-SIGNAT~RE~ r .. ~ -=116b.L1CENSEN~/3AS-
<br />
<br />[J Cremation [J Enlombment 16d. CEMETERY, CREMATORY OR OTHE~TION CITY / TOWN
<br />
<br />o Divorced 0 Unknown
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />
<br />M.
<br />
<br />Smyers
<br />14b, RELATIONSHIP TO DECEDENT
<br />
<br />wife
<br />16c. DATE (Mo" Day, Yr. )
<br />
<br />Jul 18, 2007
<br />STATE
<br />
<br />[J Removal [J Other (SpecllYL
<br />
<br />Grand Island City Cemetery
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Slreet, Clly or Town, Stale)
<br />Apfel Funeral Home 1123 West 2nd Street Grand Island,
<br />
<br />Sequentlelly 1101 condlllons, If
<br />eny, Issdlng to the caue.Usted
<br />on line..
<br />E_the UNDERLYING CAUSE
<br />(dl..... or Injury thellnltllted
<br />ths event. resulting In death)
<br />1ASf
<br />
<br />(b) Isch~mic Car~iomyopathy
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I
<br />I
<br />
<br />I onsel to dealh
<br />I
<br />I
<br />I immediate
<br />I onset to dealh
<br />I
<br />I
<br />lu~known
<br />
<br />I onsel to deeth
<br />I
<br />I
<br />
<br />respiratory arrest, or ventricular IIbrlllalion without showing tha atlology. DO NOT ABBREVIATE, Enler only one cause on eline. Add additionalliM' if necessary.
<br />IMMEDIATE CAUSE:
<br />
<br />IMMEDIATE CAUSE (Fln.'
<br />dl..... or condlllon ,""ulllng
<br />In_)
<br />
<br />~diac Arrest
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I,.
<br />
<br />onsatto death
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contribuling 10 the death but not resulting In Ihe underlying cause given In PART I,
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />Xi YES --"tTNO
<br />
<br />20, IF FEMALE:
<br />[J Not pregnanl within past year
<br />[J Pregnant alllme 01 dealh
<br />[J Nol pregnant, but pregnant within 42 days of dealh
<br />[J NOI pregnant, but pregnant 43 days to 1 year before death
<br />o Unknown jf pregnant within the past year
<br />
<br />21e. MANNER OF DEATH
<br />Illl Nalural [J Homicida
<br />
<br />[J Accldent[J Pending Inve,tigalion
<br />[J Suicide [J Could nol be detarmined
<br />
<br />21b, IFTRANSPORTATION INJURY
<br />[J Driver/Operator
<br />
<br />[J Passenger
<br />
<br />[J Pedestrian
<br />
<br />[J Other (Spacify)
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />[J YES
<br />
<br />.lO NO
<br />
<br />[J YES CI NO
<br />
<br />
<br />21d. WERE AUTOPSYFINDINGSAVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />[J YES ~ NO
<br />
<br />22a, DATE OF INJURY (MD., Day, Yr.)
<br />
<br />22b. TIME OF INJURY 22c, PLACE OF INJURY-At home, ferm, slreet, factory, office building, cnnslru~tiQn site, elc. (Specify)
<br />rn'
<br />
<br />22d, INJURY AT WORK?
<br />
<br />221, LOCATION OF INJURY. STREET & NUMBER, APT NO.
<br />
<br />CITYIfOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (MD., Day, Yr,)
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />Au ust..J, 2007
<br />
<br />24b. TIME OF DEATH between
<br />9:00 am & 10:00 am
<br />
<br />m
<br />
<br />$~~
<br />_a:
<br />
<br />U5~
<br />!i~~~
<br />"IIlZ
<br />.2lZ=>
<br />00
<br />t2a:U
<br />8 ~
<br />
<br />24c. PRONOUNCED DEAD (MD., Day, Yr.)
<br />
<br />24d, TIME PRONOUNCED DEAD
<br />a m
<br />
<br />Ll.... 2007
<br />23b. DATE SIGNED (Mo., Day, Vr,)
<br />
<br />23c. TIME OF DEATH
<br />
<br />23d. To the best of my knowledge, death occurred at the lime, date and place
<br />and due to the cause(s) stated. (Signature and Tille) ...
<br />
<br />25. DID TOBACCO USE CONTRiBUTE TOTHE DEATH?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />Nol Applicable II 26e is NO IJ YES ~ NO
<br />
<br />St., Grand Island NE 68801
<br />
<br />26a, REGISTRAR'S SIGNATURE
<br />
<br />26b. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />AUG
<br />
<br />920
<br />
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