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<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES 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
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SN;nON, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. k ~l;{ '1t~,"7:_.
<br />
<br />DATE OF ISSUANCE ""_._-':~~~~~~iR
<br />
<br />APR 0 ~ ?nnA 2008 0 94 8 3 ASSISTARr- ltIfEc;Wrft~f{~i/
<br />LINCOLN, NEBFfA~A HEALTt;!At:/D 1JtIMN<$Ii_!i '
<br />~ : S...... E l'J...' .~......;..~"..
<br />~, :~ ltc- I'....... -..
<br />.. '~ ' '" ".,.., .
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FIN~l(l'i A~ supp
<br />CERTIFICATE OF DEATH ~:',C' ..:....;1}
<br />1. DECEDENT'S.NAME (~I~m Middlo, Last,' Sullix) 2. !i~, .J 4 ".
<br />Marjorie Maxine Batie Fenta1.e I: l;
<br />
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />50. AGE.La" BI'thday
<br />(Y".)
<br />87
<br />
<br />e.OATEOF BIRTH (Mo., Day, Y'.)
<br />
<br />York, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506-09-6080
<br />
<br />April 4. 1920
<br />
<br />ea. PLACE OF DEATH
<br />.~
<br />
<br />lIlnpatiBn~ _
<br />
<br />o:Il:lEa Q Nursing HomeJLTC 0 Hospice Faclllly
<br />
<br />eb. FACILITY-NAME (II nol inslltullon, give Weet and numbor)
<br />
<br />o ER/Oulpatlenl
<br />
<br />o Decedenl's Home
<br />
<br />BryanLGH Medical Center East
<br />Be. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Lincoln 68506
<br />
<br />Q ro>. Q Other (Speclly)
<br />Bd. COUNTY OF DEATH
<br />Lancaster
<br />
<br />!lb. COUNTY
<br />Hall
<br />
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />11!1 YES 0 NO
<br />
<br />90. RESIDENCE.STATE
<br />Nebraska
<br />gd. STREET AND NUMBER
<br />1427 N. Grand Island Ave.
<br />100. MARITAL STATUS ATTIME OF DEATH Xl Married Q Nom Marriod
<br />
<br />9t. ZIP CODE
<br />68803
<br />
<br />lOb. NAME OF SPOUSE (Fi"\, Middlo, Lasl, Sulllx) II wile, give maldan namo.
<br />
<br />o Married, bl.ll separated 0 Widowed 0 Divorced 0 Unknown
<br />
<br />
<br />Maiden Surname)
<br />Phillips
<br />
<br />11. FATHER'S.NAME (FI""
<br />John
<br />
<br />Middle,
<br />
<br />L.llst,
<br />Wilson
<br />
<br />12. MOTHER'S.NAME (FI"I,
<br />Fernlea
<br />
<br />Middle,
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give date. of ee,vieo II yes. 14a.INFORMANT.NAME
<br />
<br />, 4b. RELATIONSHIP TO DECEDENT
<br />
<br />(Yes, no, or unk.) No
<br />15. METHOD OF DISPOSITION
<br />Xl Burial Q Donallon
<br />
<br />Lyle Batie
<br />
<br />Husband
<br />lBo. DATE (Mo., Day, YL)
<br />March?-9 2008
<br />STATE
<br />
<br />
<br />(J Cremation 0 Entombment
<br />
<br />led. CEMETERY, CR~MATORY OR OTHER LOCATION
<br />
<br />CITY /TOWN
<br />
<br />o Romoval Q ome' (Speclly)
<br />
<br />Grand Island Cit
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Strool, CIly arTown, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street,
<br />
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />17b. Zip Ccdo
<br />68801
<br />
<br />
<br />.'
<br />
<br />
<br />PART I. Enter the cnRln nl eventsudlseases, Injuries, or complicaUonllnlhat dlreclly eaul!led the death. DO NOT enlef termInal events euch as cardiac: arrasl,
<br />respiratory atrest, or ventricular IIbrilla.lion wilhoUI showing the etiology. DO NOT ABBREVIATE. Enter only one cause On Ii line. Add addllionalllnes ir necessary.
<br />
<br />IMMEDiATE CAUSE (Final
<br />dl........ condition ".ultins
<br />In deo1h)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />(a) ~1L,o..l- A-vlliht-
<br />
<br />cn.ellc deelh
<br />
<br />/zh"/,,ty S
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on.etlo dealh
<br />
<br />(b) Y;"lu2..-lA __~ff- 4-
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />I WeL1i..,
<br />
<br />Sequentlolly 110' condlllono, II
<br />any,leadlng 10 Ih. cauoellsted
<br />on line a.
<br />Entortho UNDERlYING CAUSE
<br />(dl..... or Injury Ihollnlll..ed
<br />tho ....,1. raoulllng In deolh)
<br />lASI"
<br />
<br />onsel to death
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I on88110 death
<br />
<br />(d)
<br />
<br />, B. t4y~~I~ITIONs.condluon. conlributlng 10 lho doalh bu' nol ,e.uIUng in Iho undo'lying causo givon In PART I.
<br />
<br />, 9. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />Q YES If NO
<br />
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />
<br />20.IF FEMALE;
<br />Ia..Not pregnant within past year
<br />Q Pregnant al lime of death
<br />Q Not p'ognant, but pregnanl wllhin 42 days 01 do..h
<br />l:l Nol pregnant. but pregnant 43 days to 1 year belore de-Ilth
<br />Q Unknown II pregnan' wlihln the pael year
<br />
<br />21a. MANNER OF DEATH
<br />}'Natural 0 Homicide
<br />
<br />Q Accldon,D Pondlng Inve.tlgatlon
<br />o Suicide l:J Could nol be delermlned
<br />
<br />21 b.IF TRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />Q passeng.,
<br />
<br />Q Pede.trlan
<br />
<br />Q Olhor (Speclly)
<br />
<br />Q YES Ai(NO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES QNO NIPr
<br />
<br />22d.INUURY AT WORK?
<br />
<br />
<br />22a. DATE OF INJURY (Mo.. Doy, Yr.)
<br />
<br />22b. TIME OF INJURY 220. PLACE OF INJURY.At home, larm, street, factory, aHics building, eonl!iltucUo., Glte, etc. (SpeCiily)
<br />m
<br />
<br />Q YES Q NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITY/TOWN
<br />
<br />SWE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo.. Day, Yr.)
<br />March 24, 2008
<br />
<br />2... DATE SIGNED (Mo., Day. y,,)
<br />
<br />24b. TIME OF DEATH
<br />
<br />~j~
<br />11110:
<br />I~~
<br />c.D. iI( ~
<br />~,~~
<br />~~8
<br />8~
<br />
<br />m
<br />
<br />23c. TIME OF DEATH
<br />12:27 a. m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Y,.) 2411. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24s. On lhe basis of examll'1allo., and/or Investigation, in my opInion death OCCurred at
<br />the time, dale Ilnd place and due 10 the caLlse(s) staled. (Signlllure and Title) 'f
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />DYES t!t. NO Q PROBABLY 0 UNKNOWN Q YES d-No
<br />VNAME~:hTLEAND ADDRESS OF CERTlFIER-(PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or P,;nl)
<br />David H. Bin ham Stre
<br />
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable II 26a is NO 0 YES
<br />
<br />NO
<br />
<br />
<br />\ I
<br />~II
<br />~
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo.. Day. Yr.)
<br />
<br />MAR 3 1 2008
<br />
<br />HHS-6111/03(55061)
<br />
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