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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT pj: Hf5At.-r~M~'1'9.MAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE..NEM.. ..'A~\'t1..' ..f! P~'R.tiJJ.. .,.:n;. '. '~F. . HE.... AL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITOR. ...~~. .~'b~. .!~..f.WA.l '~c@:"""/"""~'/"'<;:' ~.J)
<br />
<br />DATE OF ISSUANCE .~~. '. ..~,
<br />JUL 2 2 2008 :." ~ANL.i';W".. ~~~qQ..Pr.R R .' : C:' ':; ,
<br />.:: ~5IS0VOffim.BEGI5~AR
<br />2 0 0 8 0 6 7 5 4 l,~ ~f.RTMENT OFtlllAI. 7fHiiNfl
<br />LINCOLN, NEBRASKA ','1 ffFJMlJ~ERVICES, \~... c.ry} ~y
<br />~ ",' 1: .... '$'i"Jf1!JI <",\...... K -'
<br />'J 1/;,<",.,. ...cn '~...... ..' 'I '\ .....,
<br />.,' <Jl' ........ 1''0;;:'~'"
<br />, ~. . JtJ, \' '\. .. ....
<br />\ STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FIN~~ ~O .SUP~ 7 8
<br />CERTIFICATE OF DEATH . "",'" _ ~
<br />
<br />
<br />4. CITY ANO STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa, AGE.La.t Birthday
<br />(Y..,)
<br />
<br />1. DECEDENTS.NAME (First,
<br />William
<br />
<br />Middle.
<br />D.
<br />
<br />Last,
<br />Myers
<br />
<br />Suffix)
<br />
<br />2. SEX
<br />Male
<br />
<br />3. DATE OF DEATH (Mo.. Day. Yr.)
<br />July 11. 2008
<br />
<br />76
<br />
<br />
<br />8. DATE OF BIRTH (Mo.. D8Y. Yr;)
<br />
<br />Benedict, Nebraska
<br />
<br />November 19, 1931
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />505-38-9271
<br />
<br />" . ~~A~E Of DEATfJ
<br />1!QSflfAL: Olnpafieot
<br />
<br />QIllal: - DI~uralnglfllmelLlCa HoI""",faciily
<br />
<br />Bb. FACILITY. NAME (If not Instltullon, give 8treet end number)
<br />
<br />o EAlOutpatlent
<br />
<br />o Deoed.nt'. Home
<br />
<br />Tiffany Square Care Center
<br />
<br />OOCl'l
<br />
<br />o Omer (Specify)
<br />
<br />6C. CITY OR TOWN OF DEATfJ (Include Zip Code)
<br />Grand Island, 68803
<br />
<br />Sd. COUNTY OF DEATH
<br />Hall
<br />
<br />9b. COUNTY
<br />Hall
<br />
<br />
<br />9f. ZIP CODE
<br />68803
<br />
<br />9g. INSIDE CITY LIMITS
<br />. YES CJ NO
<br />
<br />9d. STREET AND NUMBER
<br />4221 West Capital Av
<br />
<br />lOa. MARITAL STATUS AT TIME OF OEATH g[Marrled 0 Never Married lOb. NAME OF SPOUSE (Flrel, Mlddl., La.t. Suffix) If wife. give maiden name.
<br />
<br />Q Divorced CJ Unknown
<br />
<br />Phyllis Kieborz
<br />
<br />CITY I TOWN
<br />
<br />Middle, Mald.n Surname)
<br />Shipferling
<br />
<br />Hb. RELATlONSfJlP TO DECEO-;i;1
<br />Wife
<br />
<br />lSc, DATE (Mo.. Dey, Yr.) I
<br />Jul 14, 2008
<br />-j
<br />
<br />I
<br />I
<br />~
<br />
<br />STATE
<br />
<br />fl. FATfJER'S.NAME (Firsl.
<br />Lynn
<br />
<br />Middle.
<br />
<br />Laal,
<br />
<br />sum.)
<br />
<br />12, MOTHER'S.NAME (Fir.t.
<br />Elsie
<br />
<br />o Cremalion 0 Enlombment
<br />
<br />
<br />16b. LICENSE NO.
<br />1092
<br />
<br />f3. EVER IN U.S. ARMED FORCj.~GI'P~;laio~g3vica if yas_ 14a.INFORMA~T.NAME
<br />(Vas,no.orunk.) Yes Apr 23, 1955 PhyllJ.s Myers
<br />--~._._'-,~~---
<br />15. METfJOD OF OJSPOSITION 16a. EM R-SIGNATURE
<br />HBurlel 0 Donallon
<br />
<br />o Removal QOthar(Spaclly) Litchfield Cemetery
<br />
<br />Litchfield
<br />
<br />NE
<br />
<br />17a. FUNERAL fJOME NAME AND MAILING ADORESS (Slreel, Clly or Town, Stale) 3005 SO. Locust Street.
<br />Curran Funeral Chapel_ Grand I_slan.ti" NE
<br />
<br />PART I. Enter Ihe ~Q!jyfJlJ~--dlee..es, InJurlas, or complleatlons..that directly caused Ihe death. 00 NOT enlar termlnel.ysnl. .uch.. c.rdlac ."..t,
<br />'e.p".tory arr..I, or ventricular Iibrill.lion wilhoulshowing the .tiology. 00 NOT ABBREVIATE. Eolar only cne cause on ellne. Add eddlllonallln..lf n.c...sry.
<br />
<br />. IMMEDIATE CAUSE (FIn.,
<br />dlsase or c::ondition r..ulUng
<br />In deelh)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />_~a~~ c.....:;..r.c-\,..... O.....-c......
<br />DUE TO, OR AS A OONSEOUENOE OF:
<br />
<br />onset 10 d.alM
<br />
<br />1;..sm"'!uentleIlY 1101 condlllon., if
<br />~, Ieodlng 10 !he aause liBleo
<br />"on IInee.
<br />EnterIhoUNDERlYlNG CAUSE
<br />(dla.... or Injury thatlnlll.teO
<br />the evenlll ...ulllng in _h)
<br />
<br />.,~T
<br />~t .
<br />
<br />(b)
<br />
<br />.J-. J~..:.
<br />
<br />'0-
<br />~~
<br />
<br />~nset to death
<br />
<br />o-t
<br />
<br />~UE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />(c)
<br />
<br />16. PART II. OTfJER SIGNIFICANT CONDITIONS-Condition. contributing to Ihe dealh but nOI rasultlng In the underlying cause given In PART I.
<br />
<br />~9. WAS MEDICAL EXAMINER
<br />I OR CORONER CONTACTED?
<br />Q YES :lfl NO
<br />
<br />ons~tto d;alh---""~----1
<br />
<br />!
<br />--j
<br />I
<br />i
<br />
<br />.~NO
<br />
<br />:,.~~~,:~,
<br />
<br />, DUE TO, OR AS A OONSEQUENCE OF:
<br />
<br />(d)
<br />
<br />o Not pregnanl within poOl year
<br />.,p pregn.nl'l time of death
<br />o NOI pregnent, bUI pregn.nl wllhln 42 days of d..fh
<br />Q Nol pr.gnanl. but pregnant 43 d.ys fo 1 yaar before oealh
<br />~nown if pregnent within the pesl y.ar
<br />. ~2a. DATEOFIt.iJURY(Mo:Doy. Vr.) L TIME OF INJURY
<br />. m
<br />22d.INJURY AT WORK? 22._ DESCRIBE HOW INJURV OCCURREO
<br />
<br />o Accld.nlO Pending Inv.stigatlon
<br />
<br />21b.IFTRANSPOATATION INJURY
<br />o DlIver/Op.r.tor
<br />
<br />CJ P....ng.r
<br />
<br />o p.desl,lan
<br />
<br />CJ Olhar (Specify)
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />20. IF FEMALE:
<br />
<br />21 a. MANNER OF DEATH
<br />R Naturel 0 fJomlclde
<br />
<br />o YES
<br />
<br />CJ Suicide CJ Could not be determln.d
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o ~!'..I!__ 0 No..__..__
<br />
<br />22C. PLACE OF INJURY.At hom.. farm, .tr.et, fectory, office building. construction .Ite. etc. (Specify)
<br />
<br />221. LOCATION OF INJURY - STREET A NIJMRF.R. APT NO.
<br />
<br />ClTYfI'OWN
<br />
<br />STATE
<br />
<br />,"~,=l
<br />
<br />.J
<br />
<br />o YES 0 NO
<br />
<br />~~I
<br />I~<~
<br />Bg~i5
<br />~~8
<br />815
<br />
<br />~ OlD T08AOOOUSE CONTRIBUTETOTfJE DEATH? 26b. WAS CONSENT GRANTEO?
<br />
<br />~~ NO 0 PROBABLY 0 UNKNOWN 0 YES g[ NO Not Appliceble if 2.e ie NO 0 YES g[ NO
<br />27. NAME, TfTLE AND AODRESS OF CERTIFIER (PHYSICIAN. CORONER'S PHVSICIAN OR COUNTY ATTORNEY) (1\1pe or Prim)
<br />Kenneth L. Vettel M.D. 2116 W. Faidley AV Suite 40~ Grand Island. NE 68803
<br />
<br />248. DATE SIGNED (Mo., Dey, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD {Mo., Dey, Yr.} 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24.. On the booi. of ..amlnetlon end/or Inve.tlgallon, In my opinion dealh occurred at
<br />the time. date aod placa and due to tno ceu.e(.} Sleted. (Slgnalure and Tille) 'f'
<br />
<br />26a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Oay, Yr.)
<br />
<br />11 /
<br />
<br />1/
<br />
<br />
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