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<br />STATE OF NEBRASKA .......w ;l,tjl.L1H Atlo""~a
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HE#:H:i4~~Ai4lt9lifNo;A
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORI{;lfW" mi mvf4jtJ?,'#tfj'';/j
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITA}. S~~r-rCS SEc;I/JJN, WHIClf1$ "-;,
<br />
<br />::~::~S::::RY FOR VlTALiolrso 964 2 ~,~~;t ~).~ ;
<br />
<br />MAR 2 5 2008 ~~~'~~NLEY s. cO,!P~ .J
<br />A~/sr4N~ f:W'l @.~'fif1tFf'/
<br />LINCOLN, NEBRASKA HEAL{1f,ftjD flfJMjS.N.BE~
<br />STATE OF NEBRASKA. DEPARTMENT OF HEALTH AND HUMAN 91S~VI. y .. c..'
<br />I ""-.. ,. ,
<br />
<br />
<br />....
<br />
<br />1. DECEDENTS-NAME (Flrs~ Mlddl., L..~ Suffix)
<br />
<br />
<br />
<br />2. SEX
<br />
<br />\
<br />I
<br />J
<br />
<br />Charles Russell Phel S
<br />4. CITY AND STATE OR TERRITORY, DR FOREIGN COUNTRY OF BIRTH
<br />
<br />Male March 14, 2008
<br />
<br />k. UNDER 1 DAY I. DATE DF BIRTH (Mo., Ooy, Yr.)
<br />
<br />HOURS MINB.
<br />
<br />k AOE-La.. BIrthcia)' lb. UNDER 1 YEAR
<br />(Yrs.l MOB. DAYS
<br />
<br />74
<br />
<br />January 6, 1934
<br />
<br />Fairbury, Nebraska
<br />
<br />1. SOCIAL SECURITY NUMBER
<br />
<br />Bo. PLACE OF DEATH
<br />~ IXIlnp.ti.nl
<br />o ERlOulpell.nl
<br />ODOA
<br />
<br />o Oth.I1Specity)
<br />
<br />8b. FACILlTY-NAME (If not In.Ulutlon, give .treel.nd numb.r)
<br />
<br />~O Nursing Home/lTC
<br />o Decedenr. Home
<br />
<br />o HOIpl~. F.~llIty
<br />
<br />508-36-0894
<br />
<br />BryanLGH Medical Center East
<br />
<br />w
<br />z
<br />~
<br />~
<br />1:
<br />!E
<br />i
<br />Q.
<br />8
<br />(J
<br />&:
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<br />
<br />8~. CITY OR TOWN OF DEATH (In~lud. ZIp Cod.) ed. COUNTY OF DEATH
<br />Lincoln 68506 Lancaster
<br />h. RESIDENCE.sTATE Db. COUNTY
<br />
<br />
<br />Nebraska Hall
<br />Id. STREET AND NUMBER
<br />1615 N. Taylor
<br />lOa. MARITAL STATUS AT TIME OF DEATH 0 M.nI.d
<br />o M.nled, but"plrsted iii Widowed D Dlvo~ed
<br />
<br />Dg. INSIDE CITY LIMITS
<br />
<br />IKI Y.. 0 No
<br />
<br />III. ZIP CODE
<br />68803
<br />o N_ M.nled lOb. NAME OF SPOUSE (Flrsl, MlddlD, LI.I, 8uIIlKllf wlfe, glYI mol..... name.
<br />o Unknown
<br />
<br />
<br />12. MOTHER'S-NAME (FI..~ Mlddl., Melden Sum.mel
<br />
<br />11. FATHER'S-NAME (Flrsl, Mlddl.. LI.~ SuffiK)
<br />
<br />Claude William Phel s
<br />
<br />13. EVER IN U.S. ARMED FORCES? GI.. d.I.. of ....Ie. If Y...
<br />
<br />(Y.', No. orUnk.) Yes Unknown
<br />
<br />15. METHOD OF DISPOSITION
<br />o Burl.' DOonltlon
<br />
<br />(jIe,.rnatlan DEntDmb....IU
<br />DRlmoVlI DOIhllrC8pecify)
<br />
<br />Mabel Mar aret Russell
<br />
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Son
<br />
<br />lee. DATE (Mo., D.y, Yr.)
<br />March 18. 2008
<br />STATE
<br />
<br />Westlawn Memorial Park Crematory
<br />11.. FUNERAL HOME NAME AND MAILING ADDRESS (Slrogl, City or Town, Stele)
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />11b, Zip Cod.
<br />
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />
<br />CAUSE OF DEATH (See Instructions and exam les
<br />
<br />1'. PART I. Enter th_ t:hallt of ..,.,.U; _ dl....... inJurt... or e:ompllc:IUon....... dlfllctty C".uMd the .....n. DO NOT .ntlr tinnlNlI events 'Ql:h ., CIIn1"C amlt"
<br />tetplratory 1ITnt, or ventrlc:ullr r1brllt.llo" without: IhaWlng the ettotogy. DO ~OT "'BREVIATE.. ~t onfV on. ClU.. on aUnl. Add _dItto",llIn..1f n~IMtJ.
<br />
<br />IMMEDIATE CAUSE,
<br />
<br />
<br />.) ft'\(.................\'G..
<br />OUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />68801
<br />
<br />I APPROXIMATE INTERVAL
<br />I
<br />: on.e~ d..th
<br />
<br />: lJA S
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />dl....1 or condition resulting
<br />In d..th)
<br />
<br />: Onllet to d4llath
<br />: etA")
<br />I
<br />
<br />Sequentially Ilat conditions, If b)
<br />anYI leading to th. c.u..lIst.d
<br />on line 8.
<br />
<br />o~o
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />: One" to death
<br />I
<br />I
<br />I
<br />I
<br />I on..t 10 de.th
<br />I
<br />I
<br />I
<br />I
<br />
<br />Enl.r th. UNDERLYING CAUSE cl
<br />(dl..... or Injury Ih.llnltlelod
<br />the ...nle ...uIUng In d.oIhl
<br />LAST
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />d)
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<br />It:
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<br />
<br />18. PART II. OTHER SIGNIFICANT CONDmONs.condltlon. contrtbullng 10 th. d..th but not relUlllng In th. und.~ylng c.... gl..n In PART I.
<br />
<br /><9 ~~J )~{" ~e...,Dw( 0 I !,-U..g (j) C,.....,l...... ....p~1h
<br />
<br />21.. MANNER OF DEATH 21b.IF TRANSPORTATION INJURY
<br />'KN.lurel D Homlcld. 0 DrlverlOp.rslor
<br />o Accldenl 0 P.ndlng In...tig.llon 0 P....ng.r
<br />o Sulcld. 0 Could nol b. det.rmln.d D P.d..trt.n
<br />D Oth.r (SplClfy)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />DYES ONO
<br />
<br />n. WAS MEDICAl EXAMINER
<br />OR CORONER CONTACTED?
<br />DYES Ii!!! NO
<br />
<br />20. IF FEIIlALE:
<br />
<br />21...WAS AN AUTOPSY PERFORMED?
<br />DYES IllINO
<br />
<br />D Not pregnont within p.sl y..r
<br />o prsgn.nt et lime of d..th
<br />o NOI pregn.n~ but pregnonl within 42 d.y. of d..th
<br />o Not pregnenl, bul pregn.nl43 days 10 1 yoer befors d..lh
<br />o Unknown II prsgn.nt wllhln Ih. p..1 yo.r
<br />
<br />22d. INJURY AT WORK?
<br />
<br />DyES ONO
<br />
<br />
<br />220. DATE OF INJURY (Mo.. Day. Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY-AI home, f'rm, '!re.L tDCtory. ofIlc. building, con.trucDon ell., ....(Specify)
<br />
<br />22f. LOCATION OF INJURY - STREET & NUMaER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />z
<br />!':$
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<br />Ji!c,.
<br />""0...J
<br />E ..,z
<br />SSO
<br />"'0
<br />.c"
<br />~~
<br />
<br />
<br />248. On the ._1. of .Kamln.lIon Indlor Inv..UgaUon, In my opinion duth occurred
<br />01 th. lime, d.l. .nd pIOC. .nd due to Ih. ceu..(.) .tet.d. (Slgnslure and TIU.1
<br />
<br />240. DATE SIGNED (110., Oey, Yr.)
<br />
<br />24b. TIllE OF DEATH
<br />
<br />...~il:i
<br />.cuz
<br />-g:
<br />a: III 0
<br />l!~I=>-
<br />""a.. <( .J
<br />~ [/If;: i!i
<br />..fliz
<br />.cZ~
<br />o:i10
<br />... Ou
<br />u15
<br />
<br />~OoK
<br />. TIME OF DEATH ""J'1 PM)
<br />1~\'1(/_
<br />
<br />m
<br />
<br />24<. PRONOUNCED DEAD (Mo., Doy. Yr.) 24d. TIME PRONOUNCEO DEAD
<br />
<br />m
<br />
<br />23d. To Ih. be.t of my knowl.dg., dnth occu<rld.1 the 11m., d.l. end pl.c.
<br />.nd due 10 th. eu..(.) .lel.d. (SllInoturs ond 1111.)
<br />
<br />
<br />
<br />21b. WAS CONSENT GRANTED?
<br />Nol Appllcebl.1f 2BoI. NO 0 YES ~ NO
<br />
<br />25. DIO TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />~YES 0 NO D PROBABLY 0 UNKNOWN
<br />
<br />260. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />,mYES 0 NO
<br />
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