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<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS C.oPY CAflRIES 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 .1
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTlO~'('tCHts '"
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. MMJ;.7;t --:~~~~, , " .
<br />
<br />DATE OF ISSUANCE ~rg",'~/I :~i'
<br />JUL 0 2 2008 20080786 7 ASS~jjj:~~B.EGIS=Y' J;
<br />LINCOLN, NEBRASKA HEAqj.I;liMJ.HUMAN 8E~JC6S --. ~ -;
<br />,--. ~. .~.;
<br />tiI:..-.~..: ~"6"
<br />STAT!;:OFNEBAASKA-D!;:PARTMENTOFHEALTHANDHUMANSEF\VlcESFwf$Ni~DS."". . .... : :;::; ,,)
<br />CERTIFICATE OF DEATH '; I.:) ", ..c
<br />
<br />~~~key 9ulflx) 2.S~'I1~':'" ~;e"~OO5
<br />
<br />5.. AeE-L~,t BlrUlday St. UNDERt' ..6l9f~I<IB~RjJj'i. ~,Vr.)
<br />(V",.) 88 HOURS M .~!\~p~!<....l4; 1916
<br />
<br />
<br />
<br />1. DECEDENT'S-NAME (Fifll.
<br />LeRoy
<br />
<br />MlddlA.
<br />John
<br />
<br />4. CITY AND STATO ORTORRITORY, OR FOREleN COUNTRY OF BIRTH
<br />
<br />EU'l:ak.a,Va1ley.,,&llraska
<br />
<br />
<br />7.llOCIAL SEClJAfTY NUMl!EIl
<br />505-32-0599
<br />
<br />".PLAC! 01' DI!ATH
<br />~: 0 Inp.tio.1
<br />
<br />..o:J1IB II NIlHio HomeIl.TC 0 HaojlIC:A Focllty
<br />
<br />Bb. .FAOI~ITY-NIIME (11 .01 In,lIIullon, OIYO otroot ond numller)
<br />TlffanySquare Care Center
<br />
<br />o ERIOulpollom
<br />
<br />O~'I_
<br />
<br />ao. CITY OR TOWN OF DEATH (Ine'''''' ZIp CodI)
<br />Grand Island 68803
<br />
<br />[J !Ill. [J 01""' lSl*IY)
<br />&d. COUNTY OF D!1ml
<br />Hall
<br />
<br />k RESIDStC&aTATE
<br />Nebraska
<br />
<br />Ob. OCUIIIY
<br />Hall
<br />
<br />
<br />Od.8TlI!!T ANDJ<<J_ IIU'IPCOOE
<br />3119 W. Faidley Ave., 68803
<br />lOa.MARIT~ SfAruB.ATTlME OF DEf\TIi. IIorrlt<l 0 NIVer Morrl8d _ ttlll..NAME Of 8POU8E (Fllot, Middle, Lael, Sulllx) If ..III, g/vllmaldAn noml.
<br />
<br />lIy. INSIDE CITY ~IMIT8
<br />10 YES [J NO
<br />
<br />o r.IlIrrlod,butleperlled [J Wldowtd QllIYo"'ad 0 Unknown
<br />
<br />Ruby Sanders
<br />
<br />11. FIITHER'S-NAME (Firat, Mlddl.. L.$l, sulfll)
<br />Charles E. Hickey
<br />
<br />13. EVER IN U.S. ARloED FORCES? GIv8 da.. 01 MlVIcIIl V". 14a.INPORIlANT.NAME
<br />(Yn,no,orunl<.) Yes: 1/10/42 10/19/ 5
<br />15. METHOD OF DISPOSITION
<br />alo....1 Q Donation
<br />
<br />00.._ IJEnlOmbmtnl
<br />
<br />OReonovol OOlhar(Speclfy)
<br />
<br />12. MOTHER'S.NIIME (Flrll,
<br />Agnes
<br />
<br />Middle. Moldon Surnamll)
<br />Foran
<br />
<br />141>. RE~TIQNSHIP TO DECEDENT
<br />Wife
<br />
<br />
<br />lib. UCENSE NO.
<br />/Z.yt)
<br />
<br />1'c, DATE (Mo.,lloy, Yr.)
<br />January 21, 2005
<br />
<br />STATE
<br />
<br />Nebral!lka
<br />
<br />. CITY I TOWN
<br />. Anselmo
<br />
<br />St. Anselm's Cath'oic Ceme.terY
<br />
<br />17.. RJNERAl HOllE NAME AND Ml\IUNG ADDRess' (SI"",.. O"y or To..n, Slale)
<br />Apfel-~utler-Geddes Funeral Rome, 1123 W. 2nd. Grand Island, NE
<br />
<br />
<br />
<br />18- PMlT I. E""" Ile ""oln "'_II......, injUtIa.. .r.ompllclllo....- d1_Iy_dlha d.ath. DO NOT Inll, to'mlnal_...... .....01... orroa~
<br />_I....",. _toll, or vemrl.lIIIr III1IUol1on wiIIlaul "",,",irclllla "tIolo0'. DO HOT ABBREVIATE. E....r ontt on. ..Ufl on Ilino, Add addlliOn.,li1os 1l11OOOl1S11')'.
<br />IMMEDIIlIE CAU8t:
<br />
<br />onoaIlo iIllall1
<br />
<br />
<br />v,/"u
<br />
<br />(a)
<br />DUE TO, OR AS A COtlSfOUENCE OF:
<br />
<br />11Il""llldNlh
<br />
<br />....-IV l"OOIIdlllonl..
<br />..,.........lbo_li_
<br />od 1ft..
<br />_""~tAlIU
<br />c_or....,_.._
<br />_-.gIn....,
<br />IAII'
<br />
<br />(1)) " ,1VY11 oN
<br />DUE TO. OR AS A CONIlE'QUENCE OF:
<br />
<br />onset 10 dMlh
<br />
<br />./I/~#l.lt
<br />
<br />2..W K$
<br />
<br />Ie)
<br />DUE TO. OR AtJ A CON8EOUENCE OF,
<br />
<br />onaet 10 daIh
<br />
<br />~
<br />lB. I'ART II. OTHER 81GMIFICAIIT CONDITIONS.condhlono """ltlbuting 10 the doelh but not .......Ing In Il1O undllrtytng ......gl... I. PAAT I.
<br />
<br />it. WAS MEDIOAL EXAMINER
<br />OR CORONER CONTACTI:D?
<br />a YES NO
<br />
<br />~.!17-r/1
<br />
<br />
<br />GWlI
<br />
<br />2O.IFFEM~E,
<br />o Not __ wllhill pat,....
<br />a p,..m ",llml of dMlh
<br />a Not ""',...... but pregnon! wIIh1n 4.2 doyo 01 dOoth
<br />o Mill PBll".... but pregnant 43 dlYl1ll1 "It boforo_h
<br />o Uniln".,n II prepnt ..1111'" \lie pOllyl.r
<br />
<br />21..MANNEA OFD~
<br />~tu"'l 011Omk:lilo .
<br />
<br />QA~JilontIJ _rcllnV8lllglllon
<br />
<br />o _ICIA 0 Could .... bo doIom1nld
<br />
<br />21b, IFTRANSPOA'T~ON INJURY 210. WAS AN AUTOPSY PERFOfIMEll?
<br />[J Drlv.rIOp.tolOr
<br />
<br />CJ Pll8I.ngor
<br />
<br />o Pad..tlIon
<br />
<br />o YES
<br />
<br />o
<br />
<br />21d. WEREAUTOPSY FNlINGS AYAlLAElLElO
<br />
<br />CJ 0Ihaf (Spaclly)
<br />
<br />CQMPl-ETECAlJ9E Q'oe.o:ttrI
<br />a YES '0 NO
<br />
<br />[J YES [J NO
<br />
<br />
<br />22a.1lIJE OF INJURY (Mo.. Coy, Vr.}
<br />
<br />leb. TIME OF INJURY 220. p~ OF INJURY-AI homo, fwm, .Irut. flot.1J, offl" b.ilding. ......ullllo.lIlll. olc. (Specify)
<br />m
<br />
<br />swe.-
<br />
<br />221. WCo'J'lON Of INJIRY . STAEET I NUM8EI'I; APT: NO.
<br />
<br />. . 011Yl1l1WN
<br />
<br />ZIP CODE
<br />
<br />2...... DATE SIBNED {Mo., Oay. Yr.}
<br />
<br />241>. TIME OF DEAT11
<br />
<br />~n
<br />IH~
<br />-15
<br />,f5
<br />~t
<br />
<br />m
<br />
<br />240. PRONOUNCED DEAD (Mo.. DIIY, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />1!4e. On Ihe boolo of elllllllnlllon >IIrJlot "'>MIIQIIlon,ln my opinion daolh 0l:0U1T\Id at
<br />Ill. tim_. dole and p.... And duo 10 rhe cou..I., SIIlAd. (SIgn.Iu'. >lid TIIla f ,.
<br />
<br />.2l1a. H.A8 OReAN OR TISSUE DONATIOlI BEEN CONSIDERED? 2lIb. WAS CONSENT llRAHTED?
<br />
<br />o PFIOBA8LY 0 UNKNOWN Cl YES NO
<br />ADDRESS OF CERTIFIER (PIlYSICIAN, CORONER'S PHYSICIAN OR COUNTY AT1tlRNEY) (1\Ip. or I'rII1)
<br />Colan M.U. 729N. Custer. Grand Island, HE.
<br />
<br />NoiA 1I<o~lelf26aI.140.0 YI':
<br />
<br />.NO
<br />
<br />68803
<br />
<br />2Il.. AEGI61JWl'S SlBNATUFIE
<br />
<br />
<br />28b. DIlIE FilED BY REGISTRAR (Mo" OaY. Yr.)
<br />
<br />JAN S 1 2005
<br />
<br />HHS-e111103(55061)
<br />
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