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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 RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~. ~.""'. .....~I-v.
<br />
<br />DATE OF ISSUANCE 11.
<br />TAljl.EY s..;CpOPER
<br />ASSIST4..Nt'$T<ATe RiGisrqAR
<br />HEAL TH At,"; HUMAN SE1?ltiCBS
<br />20080304G.;:/v.... ". ~, -/ ..
<br />. - , .",..,... '., ':..1
<br />STATEOFNEBRASKA-DEPARTMENTOFHEALTHANDHUMANSERVICESe;-N1~NC~N6'sl.lP\o~,,"~ 8:' '65
<br />CERTIFICATE OF DEATH ""', U B :({y.'
<br />. Middle, Last, Sulfl.) 2. SiX' ::""." _. ,~:p~o. 'F. ~EAT. H(Mo., Day, Yr.)
<br />E. Erion '.MaJ.e' <":'. :"anu~iy ;27, 2008
<br />
<br />FEB 0 6 2008
<br />LINCOLN, NEBRASKA
<br />
<br />
<br />1. DECEDENT'S.NAME (First.
<br />Eugene
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Kansas City, Missouri
<br />
<br />Sa. AGE.Laat Birthday 5b. UNDER 1 YEAR
<br />(YIS.) MOS. DAYS
<br />83
<br />
<br />5c. UNDE'Jll DAY t ,6. DATE OFBIRTH (Mo., Day, Yr.)
<br />HOURS MINS.
<br />
<br />May 23, 1924
<br />
<br />Sa. PLACE OF DEATH
<br />l:!Q.Sff[AL :
<br />
<br />o Inp.tient
<br />
<br />QlliEfJ: IX Nursing Home/LTC 0 Hospice Facillly
<br />
<br />(If not institution.. giv&' str&et ,'nl1 numb_rj
<br />
<br />Cl ERlOulp.tient
<br />
<br />o Decadent's Home
<br />
<br />Care Center
<br />
<br />o [l)\ 0 Olher (Specify)
<br />
<br />ad. COUNTY OF DEATH
<br />Hall
<br />
<br />8e. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island, 68803
<br />
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />
<br />9b.COUNTY
<br />Hall
<br />
<br />
<br />91. ZIP CODE
<br />68803
<br />
<br />9g. INSIDE CITY LIMITS
<br />II YES Cl NO
<br />
<br />9<1. STREET AND NUMBER
<br />1807 W. 1st
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH KMarriad Cl Never Married lOb. NAME OF SPOUSE (Flrsl, Middle, last, Sulfixllt wite, give melden n.me.
<br />
<br />o Married, bulsepalaled 0 Widowed Cl Divorc.d 0 Unknown
<br />
<br />Alice
<br />
<br />Grossnicklaus
<br />
<br />11. FATHER'S.NAME (Fir..,
<br />Everett
<br />
<br />Middle.
<br />
<br />L.st,
<br />Erion
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S.NAME (Firs!,
<br />Elva
<br />
<br />Middle,
<br />
<br />Meld"n Surn.me)
<br />Rice
<br />
<br />13. EVER IN U.S. ARMED FORCES? Giv. dates of service if yss. 14".INFORMANT.NAME
<br />(Yes,no,orunk.) No Alice Erion
<br />15. METHOD OF DISPOSITION
<br />DlBuriel 0 Donation
<br />
<br />o Cr"matlon 0 Entombment
<br />
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />lab. LICENSE NO,
<br />1092
<br />
<br />lac. DATE (Mo., Day. Yr.)
<br />Jan 31, 2008
<br />
<br />CITY I TOWN
<br />
<br />STATE
<br />
<br />o Removal o Othar(Speclly) Grand Island City Cemetery
<br />
<br />Grand Island
<br />
<br />NE
<br />
<br />17.. FUNERAL HOME NAME AND MAILING AODRESS (Slreet, Cily or Town, St.te)
<br />Curran Funeral Chapel 3005 South Locust Street
<br />
<br />PART l. Enter the c.ll~--diseaees. injuries, or compllcations--that directly caused the death. DO NOT enter terminal events such as ca.rdlac arrear,
<br />respiratory .rresl, or ventricular librlll.tion wlthoulShowtng the etiology. DO NOT ABBREVIATE. Enter only one caus" on . line. Add .ddltionalllnasIf nec.ssary.
<br />
<br />IMMEDIATE CAUSE (final
<br />d1..... or condition resulting
<br />indeoth)
<br />
<br />IMMEOIATE CAUSE:
<br />
<br />(0) .~ !'O.;l'y...Q SS,
<br />DUE TO, OR AS A CONSE~NCE OF:
<br />
<br />(0)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />~
<br />
<br />~. ~t\ C,
<br />
<br />ona.t to d.elh
<br />7- ~C~ s:.
<br />
<br />onaet 10 death
<br />
<br />Sequentially lial conditiona, If
<br />ony,laading 10 tho ,,"usaUsted
<br />on tin...
<br />EnlerlhaUNDElU.YING CAUSE
<br />(dlaaaa. or Injury that Inltl.1ed
<br />Ihe evemsmulling In daath)
<br />lAST
<br />
<br />onset to death
<br />
<br />(c)
<br />. DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I onaet to death
<br />
<br />(d)
<br />18. PART iI. OTHER SiGNIFICANT CONDITIONS.Condilions contributing 10 the desth but not resulling In the undarlylng c.use given In PART I.
<br />~<SIfC.>V<:-<"Cl.-~~ t.)~ ~~X
<br />
<br />o Suicid. 0 Could not be determined
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLETO
<br />COMPLETE CAUSE OF OEATH?
<br />DYES 0 NO
<br />~ PLACE.OF..jN'/uR'f-#_,i'ilnr,S1rnI;'factory, Olh1:e'tnmIl111C,'COnstruclfdlflllt;-e1C1'SlliiClly) --
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />o DriverlOpe..tor
<br />
<br />o P....ng.r
<br />
<br />o Pedeslri.n
<br />
<br />o Other (SpeCifY)
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />DYES . NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />20. IF FEMALE:
<br />Cl Not pregnant within paat yeer
<br />o pregnantet time of dealh
<br />o Not pregnent, but pregn.nt wllhln 42 d.ys ot d.elh
<br />Q Nol pregnent, but pregn.nt 43 days to 1 yaar before deeth
<br />o Unknown If progn.nl within lha pe.t year
<br />
<br />21.. MANNER OF DEATH
<br />lIN.lursl 0 Homlclda
<br />
<br />Cl Accid.nt 0 Pandlng Investigation
<br />
<br />DYES IXNO
<br />
<br />CI YES Cl NO
<br />
<br />
<br />~.. ~ATE ill' I~JU_RY (~.o".oaY.Y!L..
<br />
<br />22d.INJURY ATWORK?
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYIfOWN
<br />
<br />$WE
<br />
<br />ZIP CODE
<br />
<br />23.. DATE OF DEATH (Mo.. Day. Yr.)
<br />\ - ~,- c...CJc,'I,
<br />
<br />24.. DATE SIGNED (Mo., O.y, Yr.) 24b.TIMEOFDEATH
<br />~~i m
<br />
<br />I~ ~ 24c. PRONOUNCED DEAD (Mo.. Day. Yr.) 24d. TIME PRONOUNCED DOO
<br />f<r;~
<br />e~~~ m
<br />23d. To tho beat of my knowledge. death occurred .1 Ihe time, dat. .nd pl.ce ~ !Ii! ~ 24e. On the be.is of ...min'lion andlor Invesllgallon, in my opinion deeth occurred.t
<br />tsd.J:t th!, caus.:~:.t.d. SI netura and;;:O ~ ~ ~ the time. d.le and pl.c. and due to the ceu.e(s) stal.d. (Signature and TItle),.
<br />
<br />
<br />
<br />25. DIOTOBACCO USECONTRIBUTETOTHE DEATH? 26e. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />
<br />23b. DATE SIGNEO (Mo.. D.y. Yr.)
<br />\ - "U)" '~'l...>C '\\
<br />
<br />23c. TIME OF DEATH
<br />S',IS.
<br />
<br />?m
<br />
<br />___0 YES )i ~O 0 PROBABLY. 0 UNKNOWN __ 0 YES K NO _~_ NOI Applle.bl. if 26als NO 0 YES K NO
<br />27. NAME. TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. or Prlnl)
<br />Donald G. Wirth M. D. 2116 W. Faidley A".., '400, Grand Island, HE 68803
<br />
<br />28.. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo.. Dey, Yr.)
<br />
<br />FEB 4 Z008
<br />
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