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<br />."
<br />
<br />STATE OF NEBRASKA
<br />
<br />" :
<br />
<br />.
<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, V7TAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />
<br />...
<br />
<br />SEP 2 6 2007
<br />
<br />_.,,-;:,,~,""'i~'-"; ~
<br />~ , '"",, ,';. . '" L. ' ,,'
<br />. ,{,Co' . ~ri:~""i"'PER
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<br />.:<':'/'Yr.. #:jl(i ...... ...'...."4~,.~I'\,
<br />:[;1"1':" :,' . ','. ''''~\\~I!~\.'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMANi~~.ij~iF~~h \"';:I~.~...:, ~',2:::b.' :0
<br />CERTIFICATE OF: DEATHlf '.X :.i;' ';,' ',0
<br />"II : ~(~~~:i!t~i~r~r{Mi;:Y'Yio07
<br />\IN. ERLI2"'t ~PAlg,~(SIRTH (Mo, Day, Yr,)
<br />'. ""'~
<br />HOU s..:\,M~~"::"A~gust 2, 1917
<br />
<br />200810218
<br />200804275
<br />
<br />DATE OF ISSUANCE
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />\
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />~\
<br />
<br />Hall County, Nebraska
<br />
<br />5a. AGE'La.t Blrtnday
<br />(Yrs.)
<br />90
<br />
<br />
<br />1. DECEDENT'S-NAME (Firsl,
<br />Opal
<br />
<br />Middle,
<br />Margaret
<br />
<br />Lasl,
<br />Spiehs
<br />
<br />Sufllx)
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />506-90-1353
<br />
<br />ea, PLACE OF DEATH
<br />1:iO.S.WAL: Xl Inpallanl onJE8: 0 Nursing Hom./LTC 0 Hospice Facility
<br />
<br />("~
<br />
<br />8b~ ~ACILlTY:-NAME -(irriotlri.iituti;;n~~I~~~~t;~;1 .nd'-';-umi,.,-ry':;-
<br />
<br />,;"',.....,~.,.~'.,. <
<br />
<br />o ER/Outpatlenl 0 D.c.d.nt'. Ham.
<br />
<br />St. Francis Medical Center
<br />
<br />Oro>.
<br />
<br />o Other (Specily)
<br />
<br />Bc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island,
<br />
<br />68803
<br />
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />
<br />Hall
<br />
<br />
<br />el.ZIP CODE
<br />68803
<br />
<br />eg. INSIDE CITY LIMITS
<br />m YES 0 NO
<br />
<br />e.. RESIDENCE-STATE
<br />
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />
<br />800 Stoe er Drive
<br />
<br />ill. COUNTY
<br />
<br />10.. MARITAL STATUS ATTIME OF DEATH 0 Married 0 Never Marrl.d lOb. NAME OF SPOUSE (First, Middl., Lasl, Suflix) It wile, give maiden n.m.,
<br />a Marrl.d, bul'.paraled Q[ Widow.d 0 Dlvorc.d 0 Unknown
<br />
<br />11. FATHER'S-NAME (FirSI,
<br />Joseph
<br />
<br />Middl.,
<br />
<br />Lasl, SUfllx)
<br />Matthews
<br />
<br />12. MOTHER'S'NAME (Flr.t,
<br />Martha
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />Guy
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give d.I.. of .erylCe II yes. 14a. INFORMANT-NAME
<br />No Gerald
<br />
<br />o Burial
<br />
<br />
<br />t6a. EMBALMER-SIGNATURE
<br />
<br />16b. LICENSE NO:J,t
<br />""lJ'~
<br />
<br />CITY /TOWN
<br />
<br />, Bc, DATE (Mo.. Day, Y,- )
<br />September 21, 200
<br />
<br />STATE
<br />
<br />o Cr.mation 0 Enlombmenl
<br />o Removal Q Oth.r (Specify)
<br />
<br />Anatomical Board of Nebraska
<br />
<br />Omaha, Nebraska
<br />
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Streel, Clly or Town, Stale)
<br />Apfel Funeral Home. 1123 West Second,
<br />
<br />
<br />PART l. Enter the chaIn ot B'IsntsndiseBses, injuries, or compllcatlons--thal directly caused the death. DO NOT enl9r terminBleYsnts such 8S cardiac arrest,
<br />r.'plratory orresl, or venlrieular fibrillation wllhout 'hawing th. ellology. DO NOT ABBREVIATE. Enler only on. cause on a line. Add addltion.lllneslf nec....ry.
<br />IMMEDIATE CAUSE:
<br />
<br />o0gello death
<br />
<br />(a)
<br />
<br />f jJ l..<<
<br />
<br />
<br />~Altl.s
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on,ellO d.ath
<br />
<br />lloqU1lnllally 11.1 oondlllono, If (h)
<br />any, _1"11 to tho eou..1l111d DUE TO, OR AS A CONSEQUENCE OF:
<br />onll",o.
<br />E_the UNDERLYING CAUSE
<br />(di..... or Injury thollnlll.t.d (c)
<br />tha...nI. AJ$ultlnglndnth) DUE TO, OR AS A CONSEQUENCE OF:
<br />lASI"
<br />
<br />009.t 10 d.ath
<br />
<br />on,et to dealh
<br />
<br />(d)
<br />
<br />lB. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contrlbullno to Ih. d.ath but not r..ulling in Ihe underlying caus. Oiv.n in PART I.
<br />
<br />20. IF FEMALE:
<br />it Not pr.on.nt within past y..r
<br />o Pregnanlal fime 01 dealh
<br />o Not pregn.nl, bul pregnant wllhin 42 d.y. 01 death
<br />o Not pr.on.nl, bul preeMnt 43 .ayslo 1 year before dealh
<br />o Unknown II pr.on.nl wllhin the past year
<br />
<br />21a. MANNER OF DEATH
<br />~Natural 0 Homici..
<br />
<br />o AccidenlO Pendlno Invesllgation
<br />
<br />o Suicide 0 Could nol be det.rmin.d
<br />
<br />1 g. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />DYES :iiI' NO
<br />
<br />21b.IFTRANSPORTATlON INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Drlv.r/Oper.tor
<br />
<br />ChPj tSLn S
<br />
<br />e. I-f r
<br />
<br />o Passenger
<br />o Pedestrian
<br />
<br />DYES
<br />
<br />~NO
<br />
<br />o Olh.r (Specify)
<br />
<br />21d. WERE AUTOPSYFINDINGS AVAILABLETO
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />22a. DATE OF INJURY (Mo., Dey, Yr.)'
<br />
<br />...Jo. .I. ...,j.....
<br />22b. TIME OF INJURY
<br />
<br />~~_~..1""~.-'
<br />
<br />~_ Q.. m..
<br />
<br />~.NO
<br />
<br />DYES 0 NO
<br />
<br />
<br />22c. PLACE OF INJURY-AI homo, form, stre.l, feclory, ollico building, con.truetlon .11., ole. (Sp.cily)
<br />
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />22f.LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STIU'E
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo., Oay, Yr.)
<br />, -I )>... 0 ?
<br />23b DATE SII/tlED (MocPay, YrJ,.
<br />, - ',-0"1
<br />
<br />24a. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />23c. TI~ gF D~A!li
<br />1-5)~m
<br />
<br />~~~
<br />In~
<br />
<br />E ~U) ~ z
<br />SffizO
<br />.!~5
<br />t2a::U
<br />815
<br />
<br />m
<br />
<br />24C. PRONOUNCED DEAD (Mo.. Day, Yr.) 24d. TiME PRONOUNCED DEAD
<br />
<br />rn
<br />
<br />24e, On Ihe basis of examination .nd/or inv..lIgallon, in my opinion d..lh occurrod at
<br />Ihe time, dale and piece and due to Ihe cause(s) ,teled. (Slgnotur. and Tille) T
<br />
<br />260. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />2eb. WAS CONSENT GRANTED?
<br />
<br />DYES 0 0 PROBABLY 0 UNKNOWN 0 YES ~O Not Appllc.ble.lf 26~ i. NO 0 YES NO
<br />27. NAME, TITLE A D ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. Or Prinl)
<br />David Colan M.C. 729 N. Custer Ave. Grand Island, NE. 68803
<br />
<br />2Ba. REGISTRAR'S SIGNATURE
<br />
<br />
<br />2eb. DATE FILED BY REGISTRAR (Mo.. Dey, Yr.)
<br />
<br />
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