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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH 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. ~' " ,',' , J, 11___, '_~""
<br />
<br />DATE OF ISSUANCE fl, WVO'"
<br />5 0 9 7 A 6 TANLEY S. COOPER
<br />APR 2 0 2005 200 It ' ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA Ht;AL TH AND HUMAN SERVICES
<br />
<br />Q
<br />
<br />STATE OF NEBRASKA- DEPARTMENT OJ' HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />CERTIFICATE OF DEATH
<br />
<br />04064
<br />
<br />
<br />l,DECEDENT'S.NAME (FlrSI,
<br />Marie
<br />
<br />Middle,
<br />CordelIa
<br />
<br />lesl,
<br />Harris
<br />
<br />Sulflx)
<br />
<br />2.SEX
<br />Female
<br />
<br />3. DATE OF DEATH (Mo" Day, Yr,)
<br />A ril 3, 2005
<br />6. DATE OF BIRTH (Mo.. Dey, Yr.)
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOR,EIGN COUNTRY OF BIRTH
<br />
<br />5e. AGE.l..I Blrlhd.y
<br />(Y's.) 95
<br />
<br />~
<br />
<br />i
<br />
<br />Charlottesville, Virginia
<br />
<br />April 18, 1909
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />505-22-5616
<br />
<br />8a. PLACE OF DEATH
<br />
<br />~ Inp.;I,nl
<br />
<br />QII:I!:lJ; 0 Nur.lng Homs/lTC El Hosplc. Faclllly
<br />
<br />1::l.Q.S.flIAl.:
<br />
<br />8b. FACILITY. NAME (If nol In.lllutlon, give streel and number)
<br />
<br />St. Francis Medical Center
<br />
<br />o ER}Oulpali.nl
<br />
<br />o Decedent's Home
<br />
<br />OIX'l\
<br />
<br />o Olher (Specijy)
<br />
<br />8c, CITY OR TOVYN OF DEATH (Includa Zip ,Coda)
<br />Grand Island '
<br />
<br />68803
<br />
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />
<br />9a. ReSIDENCE.STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />916 N. Pine St.
<br />
<br />9b. COUNT'{
<br />Hall
<br />
<br />
<br />gg. INSIDE CITY LIMITS
<br />
<br />Jlil YES 0 NO
<br />
<br />Bf. ZIP CODE
<br />68801'
<br />
<br />10a, MARITAL STATUS AT TIME OF DEATH 0 Marrlad 0 Never M.rrled 10b. NAME OF SPOUSE (Flrsl, Mlddls, laal, Sulflx) If wile, glv. m.ld.n nom..
<br />
<br />o Marrl.d, bul s.paral.d r:>l Wldow.d ' 0 Divorced 0 Unknown
<br />
<br />11. FATHER'S.NAME (Flrsl,
<br />Jose h
<br />
<br />Mlddl.,
<br />
<br />, last.
<br />
<br />SuWx)
<br />
<br />12. MOTHER'S-NAME (Flral,
<br />
<br />Sally
<br />
<br />Mlddl.,
<br />
<br />M.ld.n Surnam.)
<br />Walton
<br />14b. RELATIONSHIP TO DECEDENT
<br />Grandson
<br />16c. DATE (Mo" Day, Yr.)
<br />A ril 7, 2005
<br />STATE
<br />
<br />o Crel)ialion 0 Enlombmant
<br />, 0 Remov.1 0 Oth.r ISp.clly)
<br />
<br />
<br />CITY /TOWN
<br />
<br />13. EVER IN U.S. ARMED FORCES?, Give d.I.. 01 ,.rvlc.1I ye.. 14..INFORMANT-NAME
<br />(Y.., no, orunk,) No Ron S encer
<br />15, METHOD OF DISPOSITION
<br />~Burl.1 DDon.lion
<br />
<br />16b, LICENSE NO. '''i..:;;z..r-
<br />
<br />Grand Island Cemetery
<br />
<br />Grand Island.
<br />
<br />Nebraska
<br />
<br />
<br />17s. FUNERAL HOME NAME AND MAILING ADDRESS (Slreel, Clly or Town, Stal.)
<br />Apfel Funeral Home, 1123 West Second,
<br />
<br />17b. Zip Cod.
<br />68801
<br />
<br />18. PART I. Entar th. ch.lnof .v.nls.-dl......, Inju'I.., or compllc.Uons--th.1 dlr.cUy ceusad the d.alh, DO NOT .nt.r tormlnal.vents such.. cardiac .rr.sl,
<br />"splr.tory arr.st, or v.nlrlcul.r IIbrUI.Uon wllhoUI shOWing th. oUology. DO NOT ABBREVIATE, Entor only on. cau.. on . line. Add addlUonalllne, II n.c..,.ry,
<br />IMMEDIATE CAUSE,
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />on..lto d..lh
<br />
<br />.~t Lc~~rid
<br />
<br />IMMEDIATE CAUSE (Final
<br />dls.a'. 0' condlUon "sulllng
<br />In d.alh)
<br />
<br />
<br />\,i
<br />
<br />(a)
<br />
<br />on..llo d..th
<br />
<br />#de.~-4;'C .
<br />
<br />S.qu.ntlally lI.t "Ondlllon.,II
<br />.ny, le.dlnglo Iha cause IIsl.d
<br />cmrlnBe.
<br />'Ent.r th. UNDERLYING CAUSE
<br />(dl'.... o,lnJury lh.llnltl.ted
<br />lh. .vanls "sulUng In d.'lh)
<br />I.ASf
<br />
<br />ons.llo d.alh
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on,.llo d,.lh
<br />
<br />td)
<br />
<br />lB.:PART.i1. OTHER SIGNIFICANT CONDITIONS-Ccndlllon. conl,lbullng loth. d..lh but not ,..ulling In th. underlying o.u.. glv.n In PART I.
<br />
<br />lB. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED? '
<br />DYES 0 NO
<br />
<br />
<br />~o F FEMALE:
<br />, ~ot pregnanl wllhln past y.ar
<br />0, pr.gn.nl.lllm. of d..th
<br />o NOI pr.gnant, but pr.gn.nt within 42 days of d..lh
<br />o Nol prognant, bul pr.gnant 43 day. 10 1 yesr bafore de.th
<br />o Unknown if pregnant wlleln Ih. p.st yee'
<br />
<br />21~EROFDEATH
<br />l ,:alural 0 Homicld.
<br />
<br />'0 Accld.ntD Pending Invesllg.llon
<br />
<br />21 b.IF TRANSPORTATION INJURY
<br />o Drlv.rIOp.r.lor
<br />
<br />o Pa..enga,
<br />
<br />o P.de'trl.n
<br />
<br />o O,th.r (Sp.clfy)
<br />
<br />DYES
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAilABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />o Sulcld. 0 Could nol b. d.lermlned
<br />
<br />22d, INJURY AT WORK?, '
<br />
<br />
<br />22a, DATE OF fNJURY (Mo., Dsy, Yr,)
<br />
<br />22b, TIME OF INJURY 22c, PLACE OF INJURY.At hom., larm, .tre.l, faclory, ollie. building, conslrucllon ,Ile, etc. (Specify)
<br />
<br />m
<br />
<br />o YES 0 NO
<br />
<br />221. lOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYlfOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23.. DATE OF DEATH (Mo" D.y, Yr.)
<br />April 3,2005
<br />
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />A r" 5,2005
<br />
<br />24., DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />1i~~
<br />_a:
<br />H~
<br />c.a.o:(~
<br />E.~ ~ z
<br />Ca: 0
<br />~lU
<br />]z::l
<br />~~8
<br />OL
<br /><> 0
<br />
<br />m
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr,) 24d. TIME PRONOUNCED DEAD'
<br />m
<br />
<br />24.. On Ih. b.sl. ol.x.mlnollon end/or Inv..llgallon, In my opinion do.lh occurr.d .1
<br />tha tlmB, dali end plac8 and dUB to the oause(s) staled. (SIgnature anr,f Tille) T
<br />
<br />25. DID TOY ~ 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />
<br />o yr/! NO 0 PROBABLY 0 UNKNOWN 0 YES NO Not Appllc.ble If 26. I. NO 0 YES XI NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTOR-NEY) (Typ. or Prlnl)
<br />John Wagoner M.D. 800 N. Alpha Ave., Grand Island, NE. 68803
<br />
<br />28.. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b, DATE FilED BY REGISTRAR (Mo.. Day, Yr.)
<br />'APR 1 2 2005
<br />
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