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<br />STATE OF NEBRASKA
<br />
<br />,.
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH-'AflJl'MWf1.AN SERVICES IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASI).!Jr [JfAAIP'r1:E5Nr OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY ,F9R ~N~i R~G9R~,I/ . ; . "
<br />
<br />DATE OF ISSUANCE ,;;~. ~f)~~
<br />
<br />2 0 ' {}'r~NLEY S. COOPER '. ,,"
<br />OCT 0 6 2008 0808793 : ds?IsfJNr:STe.T~-REGj::;'t{1.AR
<br />, riEPAR'i-"M&rJtVF HEAL TH:tJ;ND
<br />LINCOLN, NEBRASKA' FWMAN SERVICES ,: C):;;
<br />/ I .:--*.... <,~:~ , , ~,,' ~., .: ;;~ /~:,J /;,' ,
<br />STATE OF NEBRASKA - DEPARCMENT OF HEALTH AND HUMAN S~~\(~~.s"'~ ~5 ~~ /.0 8 '::>2' :g ot
<br />
<br />1. DECEDENTS-NAME (Flral, Mlddl., ~aal, Sufb) 2. SEX '..' ,'L T QF DEI\.'!" 1I.,Day,Yr.l
<br />Duane Edwin Donaldson Male ~ ' '. . s "tim~;.u. 2006
<br />a. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-~aal Birthday Ib. UNDER 1 YEAR Ie. UNDER 1 DAY," DAtE OF BIRTH (Mo., Day, Yr.l
<br />
<br />(Yra,)
<br />
<br />MOS. DAYS
<br />
<br />HOURS MINe.
<br />
<br />Albion, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />61
<br />
<br />January 11,1947
<br />
<br />5a. PLACE OF DEATH
<br />JlQiflIAL;. 0 Inpallonl
<br />o ERlOUlpldlonl
<br />oOOA
<br />
<br />QII:Wt. 0 Nuralng Hornel~ TC
<br />IiIllecedenl'a Horno
<br />o OtI>erjSpeclfy)
<br />
<br />o Hooplce Foclllty
<br />
<br />506-60-5166
<br />
<br />8b. FACILrrY.-NAME (If no' Inetltutlon, give street and number)
<br />
<br />1012 E. Oklahoma St.
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code,
<br />
<br />Grand Island 68801
<br />8e. RESIDENCE-STATE
<br />
<br />ad. COUNTY OF DEATH
<br />
<br />8b. COUNTY
<br />
<br />
<br />68801
<br />
<br />Nebraska
<br />8d, STREET AND NUMBER
<br />
<br />Hall
<br />
<br />9f.ZlP CODE
<br />
<br />8g. INSIDE CITY ~IMITS
<br />jg Yaa 0 No
<br />
<br />1012 E. Oklahoma St.
<br />
<br />101, MARITAL STATUS liT TIME OF DEATH iii Mon1.d 0 Never M.n1ed lOb. NAME OF SPOUSE IFlral, Mlddlo, ~.ol, sum.) If wife, glv. m.ld.n neme.
<br />
<br />o M.n1ed, bul ..par.led 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Charles
<br />
<br />
<br />STATE
<br />
<br />11. FATHER'S-NAME (Flral, Mlddlo, ~.at SufIlxl
<br />
<br />Mlddl., M.ld.n Sum.m.)
<br />
<br />Donaldson
<br />
<br />lab. RELATIONSHIP TO DECEDENT
<br />
<br />13. EVER IN U.S. ARMED FORCES? Glv. dol.. of ..rvle. If Yea.
<br />
<br />IV.., No, or Unk.) Yes
<br />15. METHOD OF DISPOSITION
<br />oBU,lo1 oDonotlon
<br />[iI Cntm.Uon 0 Enlomtnnenl
<br />o flemoyal DOttMtr18IMCtfy)
<br />
<br />Wife
<br />
<br />18b. LICENSE NO,
<br />
<br />1,397
<br />
<br />16c. DATE (Mo., D.y, Yr.)
<br />Se 'tember 30, 2008
<br />
<br />1.d'
<br />
<br />CITYITOWN
<br />
<br />Gibbon
<br />
<br />Nebraska
<br />
<br />17b. Zip Cod.
<br />68801
<br />
<br />Central Nebraska Cremation Service
<br />
<br />17.. FUNERIIL HOME NAME IIND MAILING ADDRESS (Str..t Clly or Town, St.I.)
<br />All Faiths Funeral Home, 2929 S. Locllst Street, Grand Island, Nebraska
<br />
<br />CAUSE OF DEATH See instructions and exam
<br />
<br />
<br />111. PART I. Ent., lhe ~ _ dl..I....ln.I~JItI., 0' c:ompllC:.lhm.~ th.. dltlc:tly e.u..d tM dtlth. Do NOT enlet "nonln.1 eyIIntII .ueh .1 clrdllC: .ITII",
<br />.....plratol)' amlt, or wn1rtcu..r f1brhlltfon"wlthGut 'hOWlna 1M d~OO'i: DO 'NO'f' ~.~...... DIlly uM Man_............. &~fI....4 ~ iI'~.c:"""".
<br />IMMEljlATE CAusr
<br />IMMEDIATE CAUSE (Fln.1 \ ~ n r"_
<br />dl..... orcondlllon re.ulllny .) Y\:) ftSs I VC- ~r'1 W ~
<br />In d..lh)
<br />
<br />IIPPROXIMATE INTERVA~
<br />
<br />04
<br />
<br />DUE TO, OR 118 A CONSEQUENCE OF:
<br />
<br />-
<br />
<br />Soqu.nU.lly 1101 condIUon., If b)
<br />any, le.dlng to th. cause IIst.d
<br />on 1108 II,
<br />
<br />on.et to death
<br />I
<br />
<br />I
<br />
<br />DUE TO, OR liS II CONSEQUENCE OF:
<br />
<br />Enler tho UNDERL YlNG CAUSE c)
<br />(dl..I'. or InJUry th.t Initiated
<br />IhO ...nla roaultlng In d..th) DUE TO. OR liS II CONSEQUENCE OF:
<br />LAST
<br />
<br />on..l to death
<br />I
<br />
<br />I
<br />
<br />d)
<br />
<br />-
<br />
<br />la. PART II. OTHER SIGNIFICANT CONDITIONS-Condition. eonlr1butlng 10 'h. d..lh but nol re.ultlny In \he und.~ylng couae glv.n In PART I.
<br />
<br />18. WIIS MEDICA~ EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES B'J NO
<br />
<br />II::
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<br />
<br />21<. WAS AN AUTOPSY PERFORMED?
<br />DYES mNO
<br />
<br />21b,IF TRIINSPORTATION INJURY
<br />o Driver/Operator
<br />o p....nger
<br />o P.d'ol~on
<br />o Olh.r (Specify)
<br />
<br />~1.. MANNER OF DEATH
<br />o N.turat 0 Homlcld.
<br />o Accldenl 0 pondlng Inve.llg.tlon
<br />o Sulcld. 0 Could nol be d.lennln.d
<br />
<br />20. IF FEMA~E:
<br />o Nol preyn.nl wilhln paal y..r
<br />o preyn.nl.1 time or d..1h
<br />o Nol pregn.nt, but pregn.nt wl\hln a2 d.y" of d..\h
<br />o Not pregnant, but pregnant 43 d.y. to 1 y.ar before de.th
<br />OUnknown If pregnant within th. p..t y..r
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAlLIIBLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />
<br />DYES oNO
<br />
<br />220. DATE OF INJURY (Mo., D.y, Yr.)
<br />
<br />22b. TIME OF INJURY 22e. PLACE OF INJURY-AI home, f.nn, .tre.t f.Clory, officI building, eon.truellon .it., .le.(Speclfy)
<br />
<br />22d. INJURY ~"JPRK?
<br />o YESJl.NO
<br />
<br />~2."DESCRIBE HOW INJURY OCCURRED
<br />
<br />~2f. ~OCA TION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYfTOWN
<br />
<br />STIITE
<br />
<br />ZIP CODE
<br />
<br />p
<br />
<br />
<br />28b. DATE FILED BY REGISTRIIR (Mo.. D.y, Vr.)
<br />OCT 1 2008
<br />
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<br />...D....J
<br />E ",Z
<br />8050
<br />....
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<br />>>:$iU
<br />.CI0Z
<br />11 iil u:
<br />j!~~)o
<br />a. D.. <( ..J
<br />EUl~ts
<br />Sffiz
<br />llz=,
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<br />00
<br />
<br />2.... DIITE SIGNED (Mo., D.y, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />240, PRONOUNCED DEAD (Mo., DIY, Yr.) 24d. TIlliE PRONOUNCED DEAD
<br />
<br />23e. TlMi ,F ~TH..fl1n
<br />
<br />m
<br />
<br />24.. On the baAI. of .Kamln.tlon andlor Inv..Ugatlon, In my opinion death oecurred
<br />at th. time, date .nd pl_ee and due to th. cau"(I) .tat.d. (Signature and Tltl.)
<br />
<br />260. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES ~ NO
<br />
<br />~ab, WAS CONSENT GRIINTED?
<br />Nol Appllc.bl. If ~60 I. NO 0 YES 0 NO
<br />
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