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<br />,
<br />
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH 4!JD HIJMAN~SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGI,!-Al:1l€~ ~ (JI:E.. WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST51s"f!.mr.1!~~0fI,~~H IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS, ~, ~"'~";i~ li;;~"" "-!,'.
<br />/ .;";il' ~"
<br />.. . ~~
<br />DATE OF ISSUANCE . , I' (."' .
<br />.' ;:: : TA!fLfiY Sj-COOPEfJ .
<br />- ASSfsTA ,,~/STRA11:
<br />~171tJ..i7t. ANiJHiJMANSE~,!if!s:~
<br />? . 1/'i", I';~ ' ' v....-
<br />-:: " ~'c.1!:; 'c:.~"; '. ,
<br />" , ~.. ". QnA",'" .....\.... ~.
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANt~ A~.6uPP. . , " ',,() "~5'
<br />CERTIFICATE OF DEATH " . ' vt' >(
<br />
<br />3, o.iiT~of D ArH (lAo" Day, Yr,)
<br />March 28, 2008
<br />
<br />200803402
<br />
<br />APR 0 8m.2008
<br />LINCOLN, NEBRASKA
<br />
<br />1. DECEDENT'S-NAME
<br />
<br />(Flra!,
<br />Carl
<br />
<br />MI~~IO,
<br />Everett
<br />
<br />lasl,
<br />Allen
<br />
<br />SulllX)
<br />
<br />2, SEX
<br />Male
<br />
<br />86
<br />
<br />
<br />S, DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />-- -.. -
<br />
<br />Burwell, Nebraska
<br />
<br />Sa, AGE-La.t Blrlhday
<br />(Yre,)
<br />
<br />April 15. 1921
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />490-18-3774
<br />
<br />Sa, PlACE OF DEATH
<br />
<br />l!l:l.SflIAL;
<br />
<br />ell Inpatlont
<br />
<br />~ 0 Nursing Home/LTC 0 Ho.pica Facility
<br />
<br />8b, FACILITY-NAME (If not In.Ulution, glv. .troat and numbor)
<br />
<br />o ERlOulpatlonl
<br />
<br />o Decedentls Home
<br />
<br />St. Francis Medical Center
<br />
<br />OOCi\
<br />
<br />o Othor (Specify)
<br />
<br />8c. CITY OR TOWN OF DEATH ('nclud. Zip Codo)
<br />
<br />Grand Island
<br />9a, RESIDENCE-STATE
<br />
<br />Nebraska
<br />9d, STREET AND NUMBER
<br />1022 West 4th
<br />
<br />P.O. Box 1114
<br />
<br />
<br />ad, COUNTY OF DEATH
<br />Hall
<br />
<br />68803
<br />Ilb,COUNTY
<br />Hall
<br />
<br />91, ZIP CODl;:
<br />68802
<br />
<br />9g, INSIDE CITY LIMITS
<br />1SI YES 0 NO
<br />
<br />100, MARITAL STATUS AT TIME OF DEATH ~ lAorrlad 0 Noyor Marrl.d lOb, NAME OF SPOUSE (First, Mlddl., Lo.t, Sulflx) If wlla, glv. m.'d.n n.ma,
<br />OlA.rriOd,bul..paratod OWldow.d ODlyorc.d OUnknown Penny Henderson
<br />
<br />It, FATHER'S-NAME (First, Mlddl.,
<br />Christopher Everett
<br />
<br />13, EVER IN U,S, ARlAED FORCES? Glv. dOl.. 01 .orvlcalf Y'.'
<br />(y.lnE5,~r:unk,) 9-29/1942 3/25/1945
<br />
<br />15, METHOD OF DISPOSITION 16e,EM LM -SIG
<br />
<br />ClBurial 0 Donallon
<br />
<br />La.l,
<br />Allen
<br />
<br />Suffix)
<br />
<br />12, MOTHER'S-NAME
<br />
<br />(First!
<br />Sadie
<br />
<br />Middl.,
<br />Lorene
<br />
<br />Maiden Surname)
<br />Hodgson
<br />
<br />o Cramatlon 0 Entombm.nl
<br />
<br />
<br />1411. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />t6d, CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY /TOWN
<br />
<br />16c, DATE (Mo., Day, Yr.)
<br />March 31, 2008
<br />
<br />STATE
<br />
<br />o Ramovel 0 Olh.r (Sp,cify)
<br />
<br />Grand Island Cemetery.
<br />
<br />Grand Island.
<br />
<br />171t FUNERAL HOME NAME AND MAILING ADDRESS (Str..I, City or Town, Stata)
<br />Apfel Funeral Home. 1123 West Second,
<br />
<br />PART I. Entsr the chain of AVllnlsudlse8S8S, injuries, or complicallons--that directly caused the death. 00 NOT enter terminal evenls suCh as cardiac arrest.
<br />r..plrafory arr.st, Or ventrlcul.r fibrillation without .howlng the aliology. DO NOT ABBREVIATE, Entar only on. cau.. on o line, Add additlonallln.. if n.c....ry,
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />dl.....oroondlUon...ltlng
<br />In_)
<br />
<br />
<br />
<br />10
<br />
<br />~
<br />
<br />(a)
<br />
<br />on70d'~
<br />
<br />on..t 10 d.ath
<br />
<br />Soquentl.lly 1101 condition.. If
<br />any, Ioodlng 10 tho .....lIeted
<br />OOlln...
<br />EntorIheUNOERLY1NCl CAUSE
<br />(dl"'H or InJUry Ihllllnltlaled
<br />the eventli reeulUng In death)
<br />lASf
<br />
<br />(c) .
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on..t 10 d.eth
<br />
<br />(d)
<br />
<br />NO
<br />
<br />o NOI pr.gnant within pa.1 ya.,
<br />o Pr.gnant alllm. of daalh
<br />o Not prsgnanl, bul pregnanl wilhin 42 day. of d..th
<br />Q Not pregnant, but pregnanl43 days to 1 year before death
<br />Cl Unknown If pregnant wilhln the past year
<br />
<br />210, ~NER OF DEATH
<br />~tural 0 Homlcld.
<br />
<br />o Accld.nlO P.nding I"..tlgellon
<br />
<br />o YES ~O
<br />
<br />l:l Suicide Q Could not be determined
<br />
<br />21b, IF TRANSPORTATION INJURY
<br />Q Driver/Operator
<br />
<br />o pes.ang.r
<br />
<br />o P.d..trlan
<br />
<br />o Oth.r (Sp.clfy)
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />o YES 0 NO
<br />
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES 0 NO
<br />
<br />220. DATE OF INJURY (Mo" Day, Yr,)
<br />
<br />2211, TIME OF INJURY 22c, PLACE OF INJURY-AI hom.. farm. .tr"I. laclory, olflca building, con.truclion .11., .Ic, (Spaclfy)
<br />m
<br />
<br />22d, INJURY AT WORK?
<br />
<br />221, LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />SWE
<br />
<br />ZIP CODE
<br />
<br />~U
<br />iiil'"
<br />US..
<br />
<br />~~~~
<br />!~5
<br />~a:.U
<br />815
<br />
<br />25, DID TOBACCO USE CONTRIBUTETOTHE DEATH? 260, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />
<br />~FS 0 NO 0 PROBABLY 0 UNKNOWN 0 YES NO . Nol Appllc.bl. il26a I. NO 0 YES 0 NO
<br />~. TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR C NTY ORNEY) (Type or Print)
<br />William J. Landis M.D. 2444 W. Faidley Ave., Grand Island. NE 68803
<br />
<br />230, DATE OF DEATH (Mo" Day, Yr.)
<br />March 28, 2008
<br />
<br />23b, DATE SIGNED (Mo., Day, Yr,)
<br />March 31, 2008
<br />
<br />240, DATE SIGNED (Mo" Oay, Yr,)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />Am
<br />
<br />24C. PRONOUNCED DEAD (Mo" Day, Yr,) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basIs 01 examination and/or Investigation, In my opinion death occurred at
<br />Ihallm., del. .nd place and dua to Ih. cau..(.) .Ialad. (Sign.tura and TiU. ) ...
<br />
<br />28a REGISTRAR'S SIGNATURE
<br />
<br />
<br />~......~. .... .." "'"'''
<br />
<br />. , {
<br />
<br />
<br />26b, DATE FILED BY REGISTRAR (lAo" Day, Yr.)
<br />
<br />APR 4 2008
<br />
<br />,. ~'., ;- I ~ ~~.
<br />
<br />HHS-6111/03(55061)
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