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<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, V1TAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />
<br />\
<br />
<br />
<br />DATE OF ISSUANCE
<br />SEP 26 2007
<br />LINCOLN, NEBRASKA
<br />
<br />200804275
<br />
<br />
<br />1. DECEDENT'S-NAME (First, Middle,
<br />
<br />,__Epal Margarl:!t
<br />
<br />4. CITY ANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Last,
<br />Spiehs
<br />
<br />Sa, AGE. Last Blrthdoy
<br />IYrs,)
<br />90
<br />
<br />~\
<br />
<br />Hall County, Nebraska
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />506-90-1353
<br />
<br />ao, PLACE OF DEATH
<br />HQ.S.fJIAL: Xl Inpotlent
<br />
<br />onJEB: 0 Nursing Home/LTC 0 Hospice Faclllly
<br />
<br />;--". LITY:NAME -nr;;ot"''''S'flfiiftsn791v9'''$triet ~':;d rrUm~ber) :tOr-!!
<br />
<br />;;.~.~~'-, ':"--~~"-".: ~"!
<br />
<br />o ER/Outpotlent
<br />
<br />o Decedonl's Homo
<br />
<br />St. Francis Medical Center
<br />
<br />Oll)',
<br />
<br />o Other (Specify)
<br />
<br />Be. CITY OR TOWN OF DEATH (Includo Zip Code)
<br />Grand Island,
<br />
<br />go, RESIDENCE.STATE
<br />
<br />Nebraska
<br />
<br />68803
<br />
<br />ad, COUNTY OF DEATH
<br />Hall
<br />
<br />9b. COUNTY
<br />Hall
<br />
<br />
<br />9d, STREET AND NUMBER gf. ZIP CODE
<br />800 Stoeger Drive 68803
<br />lOa, MARITAL STATUS AT TIME OF DEATH Q Morrlod 0 Never Married lOb, NAME OF SPOUSE (First, Middle, Last, Sulfl.) If wife, give maiden name,
<br />
<br />o Married, but separated iXWldowed 0 Divorced 0 Unknown
<br />
<br />99, INSIDE CITY LIMITS
<br />Xl YES 0 NO
<br />
<br />11, FATHER'S.NAME (First,
<br />Joseph
<br />
<br />Middle,
<br />
<br />Lasl, Sulfi.)
<br />Matthews
<br />
<br />12, MOTHER'S.NAME (First,
<br />Martha
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />Guy
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Son
<br />
<br />13, EVER IN U,S, ARMED FORCES? Give dates 01 service If yes. 14a, INFORMANT-NAME
<br />(Yes,no,orunk,) No Gerald
<br />
<br />Spiehs
<br />
<br />16b. LICENSE N~
<br />1"J'.;7s-""
<br />CITY !TOWN
<br />
<br />STATE
<br />
<br />15, METHOD OF DISPOSiTION
<br />o Burial croonalion
<br />
<br />
<br />160, EMBALMER.SIGNATURE
<br />
<br />16c, DATE (1,40" Day, Yr, )
<br />September 21. 200
<br />
<br />o Cremation 0 Entombmenl
<br />
<br />o Removel 0 Other (Specify)
<br />
<br />Anatomical Board of Nebraska
<br />
<br />Omaha. Nebraska
<br />
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Slreel, City or Town, Slate)
<br />Apfel Funeral Home. 1123 West Second.
<br />
<br />PART I. Enter the chain nf avonts..disea.e., injuries, or compllcalions..lhat directly cau.ed the death, DO NOT enler lerminalevenl. 'UCh as cardiac a"esl,
<br />resplralory e"esl, or ventricul", fibrillalion withoUI showing Ihe etiology, DO NOT ABBREVIATE, Enter only one ceuse on eline. Add additional lines If neceaaary,
<br />IMMEDIATE CAUSE:
<br />
<br />onaetto death
<br />
<br />IMMElllATE CAUse (AI1II
<br />dloeueorcondlllon ...ulling
<br />In_)
<br />
<br />(a) f)J w..
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />
<br />~AItIS
<br />
<br />$equontllllly 1101 condltlonl.1I
<br />any, ,..ding to the causalloled
<br />onllnoa.
<br />Enterlhe UNDERLYING CAUSE
<br />(di..... or injury \hat Inltlatld
<br />the ......nta ....uRlng In death)
<br />LASI"
<br />
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Conditions Contributing to the death bUI nol resulting In the underlying cause given in PART I.
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />DYES iiI' NO
<br />
<br />r.hfi) I5L n 5
<br />
<br />~ lfr
<br />
<br />20. IF FEMALE:
<br />"it Not pregnant wllhln past year
<br />o Pregnant at lime 01 death
<br />o Not pregnant, but pregnant wllhin 42 days 01 dealh
<br />o Not pregnant, but pregnant 43 day. to 1 year before death
<br />o Unknown If pregnant within the past yaar
<br />
<br />21a. MANNER OF DEATH
<br />~awral 0 Homiclda
<br />
<br />o AccidentO Pending Investigation
<br />
<br />21 b.IF TRANSPORTATION INJURY
<br />o Drlver/Operalor
<br />
<br />o Passenger
<br />
<br />o Pedestrian
<br />
<br />o Other (Specify)
<br />
<br />21c, WAS AN AUTOPSY PERFORMED?
<br />
<br />o YES ~NO
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />1:;1 YES 0 NO
<br />
<br />o Suicide 0 Could nol be delermlned
<br />
<br />22d, INJURY AT WORK?
<br />
<br />
<br />22a, DATE OF INJURY (1,40" Day, Yr,)
<br />
<br />22b, TIME OF INJURY 22c, PLACE OF INJURY.At home, ferm, Itreet, factory, offiCI building, conOlructlon aile, etc, (Specify)
<br />m
<br />
<br />DYES 0 NO
<br />
<br />22t. LOCATION OF INJURY. STREET & NUMBER, APT. NO,
<br />
<br />CITYtrOWN
<br />
<br />$WE
<br />
<br />ZIP CODE
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b, TiME OF DEATH
<br />
<br />,.,:'i~
<br />..Gz
<br />Ji~~
<br />f~~!
<br />1l!!
<br />,2g~
<br />
<br />m
<br />
<br />23c. TllIF 9F D;.A~
<br />1.~)t1-m
<br />
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.) 24d, TIME PRONOUNCED DEAD
<br />rn
<br />
<br />248. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time. date and place and due to the cause(s) stated. (Signature and Title) T
<br />
<br />25. DID TOaACCO USE CONTRIBUTETOTHE DEATH?
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />_,~ " 0 Y~S 0 0 PROBABLY 0 UNKNOWN 0 y~_ __ ~O NOI Applicabie if 26a Is NO 0 Y~S~.~O
<br />. 27, NAME, TITLE A D ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Prlnl)
<br />David Colan M.C. 729 N. Custer Ave. Grand Island. NE. 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />26b. DATE FILED BY REGISTRAR (1,40" Day, Yr,)
<br />
<br />
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