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<br />
<br />NOV 2 9 2007
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<br />STATE OF NEBRASKA
<br />
<br />20075315
<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 STATISTICS SECTION, WHICH IS
<br />
<br />::;;::~;~7::~TORY FOR VITAL RECORDS. ~bM. 1/ C,,~.,.,~.,
<br />NOV 3 0 200? l"..,....~~w"Jft~~()PER.
<br />ASSISTN'lr- ~t"1E/"'E~.!S.r.RAR
<br />HEALTJt.1WD HUMAN Sa.{VICt;S
<br />'" . . ~..... ~
<br />: f' .~, -'I,......' .... -'"
<br />.....
<br />~'-.' :. o.~") I'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICl::S ~NANCE AND sUPP<
<br />CERTIFICATE OF DEATH ...... ". ,
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />200803653
<br />
<br />1. DECEDENT'S.NAME (Fi"t,
<br />Elsie
<br />
<br />
<br />Middle,
<br />H
<br />
<br />Last!
<br />Nyce
<br />
<br />Suffix)
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5e. AGE-Le.1 Birthdey 5b. UNDER 1 YEAR
<br />(Y".) MOS. DAYS
<br />90
<br />
<br />October 18, 1917
<br />
<br />Campbell, Nebraska
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />522:-10-4008
<br />
<br />8a. PLACE OF DEATH
<br />1::IQSflTAl,:
<br />
<br />o Inp.tienl
<br />
<br />0lliEB:
<br />
<br />o Nursing Home/LTC 0 Ho.pice FaCility
<br />
<br />FACllITY.NAME (If not Inatllulion, giva atreal and numbar)
<br />
<br />iJ ERIOutpalient
<br />
<br />o Decedent'. Home
<br />
<br />Mary Lanning Memorial Hospital
<br />
<br />OEXll\
<br />
<br />o Other (Specify)
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Hastings 68901
<br />
<br />ga. RESIDENCE.STATE
<br />
<br />Nebraska
<br />
<br />9d. STREET AND NUMBER
<br />
<br />1504 Crestmoor Drive
<br />
<br />8d. COUNTY OF DEATH
<br />Adams
<br />
<br />9b. COUNTY
<br />Adams
<br />
<br />
<br />9f. ZIP CODE
<br />6l::1901
<br />
<br />99. INSIDE CITY LIMITS
<br />
<br />Xl YES 0 NO
<br />
<br />10.. MARITAL STATUS AT TIME OF DEATH I:l Married q Never Married lOb. NAMe O. SPOUSE (FirS!, Midale, Last, SUffix) II wife, g,ve meiden name.
<br />
<br />OMarrled,bul.eparaled alWidowed DDI.orced DUnknown Merlon Nyce (dec)
<br />
<br />11. FATHER'S-NAME (Flrsl,
<br />Alexander
<br />
<br />Middle,
<br />
<br />La.l,
<br />Koch
<br />
<br />Suffix)
<br />
<br />12, MOTHER'S.NAME (FI"t, Middle,
<br />Katherine
<br />
<br />M.iden Surname)
<br />Rehn
<br />
<br />13. EVER IN U.S, ARMED FORCES? Give dale. of .ervlce If yes, 14a.INFORMANT.NAME
<br />(Yes, no, or unk.) No
<br />IS. METHOD OF DISPOSITION
<br />iJBurlal 0 Donation
<br />
<br />f4b. RELATIONSHIP TO DECEDENT
<br />
<br />Son
<br />
<br />Cl Cremation 0 Entombmenl
<br />
<br />
<br />CITY !TOWN
<br />
<br />18b. LICENSE NO.
<br />1189
<br />
<br />16c. DATE (Mo., Day, Yr. )
<br />November 26, 2007
<br />
<br />STATE
<br />
<br />o Removal 0 Other (Specify)
<br />
<br />Rosedale Cemetery
<br />
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (Slreet, City orTown, Slete)
<br />Livin ston-Butler-Volland Funeral Home
<br />
<br />Rural Hall County
<br />
<br />1225 North Elm Avenue
<br />Hastin s Nebraska
<br />
<br />Nebraska
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onoello dealh
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl_orcondlllon_lIIng
<br />In death)
<br />
<br />(a)~.
<br />DUE TO, OR AS A CONSEQUENCE
<br />
<br />~
<br />
<br />
<br />I onoetto death
<br />
<br />Sequontielly i1st conditions, if (Ii)
<br />ony, Iqdlng tolheceuaollstsd DUE TO, OR AS A CONSEQUENCE OF:
<br />on linea.
<br />Enterlho UNDER~YING CAUSE
<br />(dl_se or Injury thsllnllleled (c)
<br />lhe_ ,""ulllng In dsalh) DUE TO, OR AS A CONSEQUENCE OF:
<br />LASr
<br />
<br />on.el to dealh
<br />
<br />onsal 10 death
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS.Condilion. conlrlbullng to Ih. deeth bUI nol r.oulllng In Ihe underlying cause given In PART I.
<br />
<br />20. IF FEMALE:
<br />II Not prElgnanl wiHlln past year
<br />o Pregnant at lime of dealh
<br />o Not pregnant, but pregnant within 42 days of death
<br />o Nol pregnent, but pregnant 43 days 10 1 year before death
<br />o Unknown if pregnant within the pa.1 year
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />o YES ~ NO
<br />
<br />121 b.IF TRANSPORTATlO~~WAS AN AUTOPSY PERFORMED?
<br />o DriverlOperator . __.n'''1 -.-.
<br />OP 0 YES ~NO
<br />assenger
<br />
<br />o Pedeotrlan
<br />
<br />210. MANNER OF DEATH
<br />~otural 0 Homlcida
<br />
<br />o AccidentO Pandlnglnve.lIgellon
<br />
<br />o Sulcld. 0 Could not be delermined
<br />
<br />o Other (Specity)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />22d.INJURY ATWORK?
<br />
<br />
<br />~~.,,{Mc..l~+--
<br />
<br />OE.../.ll.!,URY -- -22.c.-P.LACE-OE-lN..llJJU'~ weel. fa.q.torY...Q.tfic~..!ll!lJ.Qln.g~ Mo~tfJ:!~t!Q~ site, et~.,l.SpeclfYt
<br />m
<br />
<br />DYES 0 NO
<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 (MO., Day, Yr.)
<br />N~vember 21, 2007
<br />
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />November 21 2007
<br />23d. To
<br />
<br />24a. DATE SIGNED (Mo., Dey, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />~~~
<br />-15
<br />J~h
<br />~"j>-Z
<br />olrzO
<br />!~a
<br />.2a:O
<br />815
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />248. On the basis of examination and/or invBstigation, In my opinion death OCCurred at
<br />the lime, date and place and due 10 tha ceuse(s) .Iated. (Slgnalure and Tille) "
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />Cl YES ex NO 0 PROBABLY 0 UNKNOWN 0 YES cJ:NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Prlnl)
<br />Michael D. Matthews, ER RM Mary Lanning Memorial Hospital,
<br />
<br />
<br />280. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />!{ ,-,
<br />
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