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<br />,
<br />
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALT.J:!;ANf::r~N SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A . TRUE COPY OF THE ORIGINAl.. f!I:IOORDbl!..F/~E.WITH
<br />THE NEBRASKA HEALTH AND HUMAN SER.VICES SYSTEM, VITAL SJ#T~ff'9~:s..~rpo.!4 ,w";J'J?H IS
<br />THELEGALDEPOSITORYFORVITALRECO~DS. ".~. ....... "J ~"'" ".',
<br />.'1 --' ~ ~J
<br />, I . ,",,) .
<br />DATE OF ISSUANCE . . ~,i;," : ',,"\ .',
<br />r:::: . 1JW<..p Y ;:). COOP:BR,; ~
<br />MAR 3 1 2008 . A"iStsTJmr'stA're "eGlstRi't~
<br />LINCOLN, NEBRASKA 2 0 0 8 0 2 8 6 0 'HEAtH AND HUMAN SEFW~S.'
<br />. ,'" ,~<:~::<~',;.;; ,\ ~:,,/~;.~.~:\:'( .-:'
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HU~AN ~~R\;~~ ~~~~i~ AND SU~;~B
<br />_. _ CERTIr:!,CATE OF DEATH "_.. U
<br />
<br />23197
<br />
<br />Mlddla.
<br />W.
<br />
<br />Last,
<br />Nowka
<br />
<br />SuHlx)
<br />
<br />2.SEX
<br />Male
<br />
<br />Hastings, Nebraska
<br />
<br />5a. AGE.Lasl Birthday
<br />(Yrs) 67
<br />
<br />5b. UNDER I Y~AR
<br />MOS. OAYS
<br />
<br />5c. UND~R 1 DAY
<br />HOURS MINS.
<br />
<br />3. DATE OF D~ATH (Mo" Day, Yr.)
<br />March 12, 2008
<br />
<br />6. DAT~ OF BIRTH (Mo.;Day, Yr.)
<br />
<br />4. CITY AND STAT~ OR T~RRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />September 26, 1940
<br />
<br />505-48-5~J)
<br />FACILITY.NAME (If not inatltutlon, give street and number)
<br />
<br />Sa. PLACE OF DEATH
<br />J::IQSElIAl.:
<br />
<br />r:J Inpatient
<br />
<br />Qll:IEB: IX Nursing Home/LTC r:J Hospice Facility
<br />
<br />Wedgewood Care Center
<br />
<br />r:J ER/Oulpatient
<br />
<br />o Decedent's Home
<br />
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />ge.RESIDENCE.STAT~ . ~~TY
<br />Nebraska -------L____Hal1
<br />9d. STREET AND NUMBER
<br />1803 Stagecoach Rd.
<br />lOa. MARtTAL STATUS ATTIME OF D~ATH Q[M;rried 0 Never Married
<br />
<br />r:J lXlI\ 0 Other (Speclty)
<br />
<br />e. COUNTY ~~~~H
<br />
<br />
<br />91. ZIP CODE
<br />68801
<br />
<br />9g.INSIDE CITY LIMITS
<br />Xl Y~S 0 NO
<br />
<br />lOb. NAME OF SPOUS~ (First, Middle, Lasl, Suftix) If wlte, glva maiden name.
<br />
<br />r:J Married, but separated r:J Widowed 0 Divorced 0 Unknown
<br />
<br />Carol L. Alleman
<br />
<br />11. FATHER'S.NAME (First,
<br />Walter
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />SuHix)
<br />
<br />r:J Burial
<br />
<br />
<br />..1
<br />
<br />12. MOTHER'S.NAM~ (First,
<br />Anna
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />
<br />(Yes, no, or unk.) No
<br />15. METHOD OF DISPOSITION
<br />
<br />Carol L. Nowka
<br />~.. -
<br />
<br />~eye
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />13. ~V~R iN U.S. ARMED fORC~S? Give dates of service it yes. 14a.INFORMANT.NAME
<br />
<br />r:J Donation
<br />
<br />16b. LICENSE NO.
<br />/8:18
<br />
<br />15c. DATE (Mo., Day, Yr.)
<br />March 25, 2008
<br />
<br />~remaUon 0 Enlombmerll
<br />
<br />CITY / TOWN
<br />
<br />STAT~
<br />
<br />o Removal r:J Other (Spacify)
<br />
<br />BV Cremation Center
<br />17a. ~ml:\.~ ~Al'JD MAILING ADDRESS (Straet. City or Town, State)
<br />Butler Volland Funeral Horne, 1225 N. Elm
<br />
<br />Hastings
<br />
<br />PART I. Enter Ihe ~.J~"diseases, lnjuries~ or compllcallons--that directly caused Ihe death. DO NOT enter terminal events such as cardiac arrest.
<br />respiratory arrest, or ventricular IIbrillation without showing the etiology. DO NOT ABBREVIATE. Entar only one cause on aline. Add additional lines If nacessary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onset to death
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl..... or COndition 18lulllng
<br />Indealh)
<br />
<br />Saqulntillly lie' oondlllon., If (b) ~')t?'Y'4r-l\"':"
<br />eny,leldlng to lhe caulelleled DUE TO, OR AS A CONSEOUENCE OF:
<br />on IIn...
<br />Enterthe UNDERLYING CAUSE
<br />(dl_Ie or Injury thellnRlalld (c)
<br />lheeventar8lulllng In death) DUE TO, OR AS A CONSEOUENC~ OF:
<br />LAS!'
<br />
<br />la)P~
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />-- .2....vkJ.
<br />
<br />onset to daath
<br />
<br />onsel to death
<br />
<br />onset 10 death
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS.Condillons contributing to the dealh but not resulting in tha underlying CauSe given in PART I.
<br />
<br />19. WAS MEDICAL EXAMiNER
<br />
<br />OR CORON~R CONTACTED?
<br />
<br />DYES m NO
<br />
<br />CIJ.I1l'N-;> o.,~ ,~
<br />
<br />20. IF FEMALE:
<br />
<br />21a. MANNER OF DEATH
<br />~alural r:J Homlcida
<br />
<br />o AccidentO Pending Investigation
<br />
<br />Q Not pregnanl wl1hll'1 past year
<br />o Pregnant al lima 01 dealh
<br />o NOI pregnant, but pregnanl within 42 days of death
<br />o Not pragnant, but pregnenl43 days to 1 year before death
<br />o Unknown if pregnanl within the paS! year
<br />
<br />o Suicide 0 Could not be determined
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />o Drivar/Operator
<br />
<br />o Passenger
<br />
<br />o Pedestrian
<br />
<br />o Other (Specify)
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />DYES !l!I.NO
<br />
<br />DYES U NO
<br />
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />r:J YES 9(NO
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY.At home, larm, street. factory, office building, construction site, etc. (Sp'eclfy)
<br />
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY . STR~ET & NUMBER, APT NO.
<br />
<br />CITYITOWN
<br />
<br />STArE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF D~ATH IMo.. Dey, Yr.)
<br />~?,- /1.. ~ 0&
<br />
<br />23b. DATs. SIGNED (Mo.. Day, Yr.)
<br />,$- 1)- -tJ)
<br />
<br />23d. To tha best of my knowledge, dealh occurred at the time, dale and place
<br />and due to the causa,s) stated. (Slgnalure and Tille) .,
<br />{1"M-.
<br />
<br />24a. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />..~ ~
<br />.cOa:
<br />!~~
<br />e;.o. CI: ~
<br />gffi~~
<br />.8i1:=>
<br />,2Ci:8
<br />8~
<br />
<br />m
<br />
<br />23c. Tljf5~
<br />
<br />24c. PRONOUNCED DEAD (Mo., Oay, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />'"1(
<br />
<br />r--
<br />
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the lime, date and place and due to the cause(s) stated. (Signature and Tille)"
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />2Sa. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />r:J YES /!l1.,NO t:J PROBABLY 0 UNKNOWN 0 Y~S ~O
<br />2? NAME, TITLE'AND ADDRESS OF CERTiFIER (PHYSICIAN, COiiONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Anne K. Morse M.D. 729 N. Custer Ave., Grand Island,
<br />
<br />26a. REGISTRAR'S SIGNATURE
<br />
<br />Nol Applicable If 26a is NO 0 YES \!l\NO
<br />
<br />NE 68803
<br />
<br />
<br />26b. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />
<br />MAR 2 8 2008
<br />
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