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<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NE8RASKA HEAL TH A'NlHlt/MAN..SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGIN~~e.QfltI Af'J~/rE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAm~~.5Sf#ON.~~H IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. .~~. .~,."'~r:~~it,~.~',.';'~'~;.:;.::'{',,~,l.,
<br />
<br />DATE OF ISSUANCE - 1f'.~ .
<br />
<br />JUN 172008 200808583 :~i/~TA. ..'~:%~;::
<br />LINCOLN, NEBRASKA Hf~AND #:fI;lMA~JI$Rl':/~:'
<br />'~~~V~SW':~\:-" ..~) >
<br />
<br />~.
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<br /> STATE OF NEBRASKA. DEPARTMEN! ~:EAL TH AND HUMAN S V . " ',:.2:A .~? S
<br /> LI"K III-U;A II'" nFA',H ~ . ~r..'"
<br /> 1. DECEDENTS-NAME (F'rat, Mlcldlo, Last, Sum.) 2. SEX T,,-, . ".llJ4JI OlfDEl!'~.:\II<>.,DOy,Yr.)
<br /> Ii., , ~
<br /> " '," - ~,., ~ 4i., "'. o:.;;:....r
<br /> Mary Grace Liess Female ~ay '4:'20'08
<br /> .. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTIi 50. AGE-L.ol Blrthdoy lb. UNDER 1 YEAR 5c. UNDER 1 DAY I. DATE OF BIRTH (Mo" Doy, Yr.)
<br /> (Yra.) MOS, I DAYS IiOURS I MINS.
<br /> Hastings, Nebraska 47 July 29, 1960
<br /> 7. SOCIAL SECURITY NUMBER 80. PLACE OF DEA TIi
<br /> IX 505-74-8143 ~ 0 InpaUonl QIHm; Il!I Nuralng HomOIL TC D liooplco Facility
<br /> 0
<br /> tJ lb. FACILlTY-NAME (If nOllnollluUon, gl.o olraolond numb..) o ERlOutpallonl D Docodont'o liomo
<br /> ~ Wedgewood Care Center ODDA D Otho"Spoclfy)
<br /> C
<br /> ....I Ie. CITY OR TOWN OF DEATIi (Includo Zip Codo) lid. COUNTY OF DEA TIi
<br /> i:! Grand Island 68803 Hall
<br /> w
<br /> z Ia. RE$lDENCE-$TATE leb. COUNTY I 'c. CITY OR TOWN
<br /> :::l
<br /> II.
<br /> j Nebraska Hall Grand Island
<br /> 'i 'd. STREET AND NUMBER 1'0' APT. NO, T II. ZIP CODE T eg. INSIDE CITY LIMITS
<br /> !E 3110 Midway Road 68803 I&J Y.. 0 No
<br /> . lOa. MARITAL STATUS AT TIME OF DEATIi iii Marrlod o Novor M0n1edll0b. NAME OF SPOUSE (Firat, Mlddlo, Loot, SufII.) If wllo, gl.. maldon namo.
<br /> ~
<br /> ~ D M.n1.d, but .oparoted 0 Widowod o Plvorcod o Unknown Mark Liess
<br /> ii 11. FATHER'S-NAME (Flral, Loot, SufII.) 112. MOTIiER'S-NAME (Firat, Mlddlo, Moldon Sumomol
<br /> g Middle,
<br /> U Vernon Mever Phvllis Seeman
<br /> . 14b, RELATIONSIiIP TO DECEDENT
<br /> III 13. EVER IN U.S. ARMED FORCES? GI.o dOloo 01 ....Ico IfY... I ;40. INFORMANT-NAME
<br /> 0 (Yoo, No, or Unk.) No Mark L1ess Husband
<br /> I-
<br /> 18. METHOD OF DISPOSITION l~MER-SI~NAT~'a'S L 00. I lib. LICENSE NO. 18c. DATE (Mo., D.y, Yr.)
<br /> IJI Bu'" o OOnatlon U.ll...o ^-I -\.- . .CP 1~97 Mav 8, 2008
<br /> o Crwm~IIGn OEntDmbm....t 18d. ClMETERY, CREMATORY OR OTIiER LOCATION STATE
<br /> o Removal DOI"~Sp,,1fy1 /,.. CITYITOWN
<br /> Westlawn Memorial Park Cemetery Gland Island Nebraska
<br /> 170. FUNERAL IiOME NAME AND MAILING ADDRESS (SI"ot. Clly or Town, Slalo) 17b. ZIp Codo
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> CAUSE OF DEATH (See instructions and examples)
<br /> 11. PART I, Enllllr the cb.ln of 1IIvt1111~ . dl......, InJurte., Dr l:ompll.::.t10"'1II~ that dlndly iClulld 1M de.tn. DO NOT .n..r tennlnll'vtnll ,uc;:h ... c;:.rdlac ...,.,1,
<br /> T APPROXIMATE INTERVAL
<br /> 1'1II,Imary .'''., ar ve'1lJ1CI,I"r ribrlllaLlon without .hGWtno the .00100'. DO NOT AElBRlVIAll:. Enllr only one Gau.. on 111111. Add ,d~I.I"n11llln11. K nIIC....ry. I
<br /> ':M~A;;;E1u- PD1()r-l,. d,ffereYf'J.,c,rt,J ~ rt)Vb tt.{! OVdA'f... on"l to death
<br /> IMMEDIATE CAUSE (Final I 3' ~ ~A
<br /> dl..... or condition ....ultlng I .~
<br /> In dooth)
<br /> DUE TO, OR AS A CONSEQUENCE OF: 7' Ton... to d..th
<br /> I
<br /> SoquonU.lly.llot condition.. If b) I
<br /> any, I..dlng to the cau,. lIeled
<br /> on IIno I. DUE TO, OR AS A CONSEQUENCE OF: 'on..t to do.th
<br /> I
<br /> Enter tho UNDERL YlNG CAUSE cl I
<br /> (dlloa.. or Injury thltlnltllllld 'onoollo do.lh
<br /> the ..,.nls r..ultlng In ..th) DUE TO, OR AS A CONSEQUENCE OF:
<br /> LAST I
<br /> I
<br /> d) I
<br /> 11. PART II. OTHER SIGNIFICANT CONDITIONS.condltlono contrlbuUng to tho d..th bul nol ra.ultlng In tho undo~ylng COU.O gi..n In PART I. 19. WAS MEDICAL EXAMINER
<br /> ~ OR CORONER CONTACTED?
<br /> DYES ~ NO
<br /> IX
<br /> W 20. IF FEMALE: 21.. MANNER OF DEATH 21b.IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> u::
<br /> i= gNol pragnant within p..1 yo.. ~.tur.1 o Hornlcldo o D~.orIOporolor DYES i3"No
<br /> 15 o P"gnont at "mo of dooth o Accldont 0 Pondlng In...tigation o pa...ngor 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br /> U D Not pragnont, but pragnant within .2 doyo of dooth D Sulcldo o Could nat ~ d.t.nnlned o Podootriln
<br /> TO COMPLETE CAUSE OF DEATIi?
<br /> ~ o Not pregnant, but p...gnant 43 dap to 1 yuar before death D Oth.. CSpaclfy) DYES IaNO
<br /> ~ OUnknown If pragnonl within tho paot y..r
<br /> III
<br /> Ii 122b' TIME OF INJURY 1 22c. PLACE OF INJURY-AI homo, Ilrm, atroat, loclory, omco building, conotnletlon ono, otc.(Spoclfy)
<br /> g 221. DATE OF INJURY IMo.. D.y. Yr.)
<br /> U
<br /> .! 22d.INJURY AT WORK? 220. DESCRIBE IiOW INJURY OCCURRED
<br /> {!. DYES ONO
<br /> 221. LOCATION OF INJURY. STREET" NUMBER, APT. NO. CITYITOWN STATE ZIP CODE
<br /> 230. DATE OF OEATIi (Mo., Day, Yr.) Z 24a. DATE SIGNED (Mo., D.y, Yr.) ~. TIME OF DEATIi
<br /> ~~ Mav 4 2008 ~:!iti m
<br /> J~>- uz
<br /> 23b. DATE SIGNED (Mo., Diy, Yr.) 1 23c. TIME OF DEA TIi ~ Ul~ 2... PRONOUNCED DEAD (Mo., D.y, Yr.) 2:4cl. TIME PRONOUNCED DfAD
<br /> .J'U ne,. '1" J~od !;:I= >-
<br /> Q. ..J 12:35 P.m iiD..o(..J
<br /> e ",Z ~ ~~! m
<br /> SeO 23d. To Ole best of my knowledge. de.th Mcurnd at the tlm., date and pl..e 248. On the b.,I, of examination and/or InvnUgatlon, In my opinion death occurred
<br /> .."
<br /> .DC ondd7F~;';;bTltlOI !!B at tho timo, dllll.nd pl..o ond duo to tho c,ulolo) Itltad. (Slgnaturo and Tltlo)
<br /> ~ .21 .2 ~~
<br /> uo
<br />~ 25. DID TOBACCO USE CONTRIBUTE TO TIiE DEATIi? 1210. liAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 121b. WAS CONSENT GRANTED?
<br />\:: DYES )j1NO o PROBABLY o UNKNOWN DYES .m- NO Not Applleoblo If 21a 10 NO 0 YES ikI NO
<br /> 27. NAME, TITLE ANO ADDRESS OF CERTIFIER (PIiYSICIAN, CORONER'S PIiYSICIAN OR COUNTY ATTORNEY) (Typo or P~nl)
<br /> Richard Fruehling, M.D., 2116 W. Faidley Ave., Grand Island, NE 68803
<br /> 28.. REGISTRAR'S SIGNATURE ,,~. ~~ J. f~ 28b. DAlE FILED BY REGISTRAR (Mo., D.y, Yr.)
<br /> p JUN 17 2008
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