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<br />" u '. ' ~!I'i
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<br />,
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<br />STATE OF NEBRASKA
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<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL TH AN.D H!/.f'4~'-5f!VICE5.. ..'.....:i...:.T.........C. ...F.,R. r.I. F....IES
<br />THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA ?g,.Mp.~'1~fI(r/~r\if1Lf~it,;jo/ .,._
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY~FOR VITAL;1(~~4''f!S~..., " /0 I/~.. "r,l.\..:. i
<br />,- ~., \1 ". C;~ ,I, d~,;,
<br />DATE OF ISSUANCE I ~,-; .. , ,^ .I~' ~,: .ffr;- /
<br />STANLE'f'S.' COQPE1t'. "!" ", L," . ". ,I ~ ,,,) I . "'j'
<br />.. . ~if" ,iW' it(:,'r
<br />ASSI5}~-,: ST.c!fEJR!3G Sl "~I: /n / ,,},'
<br />DEPA'irrMff~T cJE)~i I : ~ ~ ~."
<br />H/,JMrA./ OFR,VICES:, . : - ~
<br />"7,- ~~ '. . A" ..... ,.' . :;: pl'
<br />. ',:l~:"f. ," C;> ..'
<br />(t (' ". .Srll\f:..,\."::,':,\ ,""",
<br />STATE OF NEBRASKA-DEPARTMENTOF HEALTH AND HUMAN SERVICES FINANCE AND suF4>o 1. J" ','. .,':,. . \J .::-
<br />CERTIFICATE OF DEATH \1 ' , ~'
<br />3. DATE o~ iIE~~tw::'ilay, Yr.)
<br />November i9, 2008
<br />
<br />.JAN 0 5 ZOOSl
<br />
<br />200900103
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />
<br />
<br />1. DECEDENT'S.NAME
<br />
<br />(First,
<br />
<br />Mlddl.,
<br />Francis
<br />
<br />Laol,
<br />Hurst
<br />
<br />Sufllx)
<br />
<br />2. SEX
<br />Male
<br />
<br />Cleo
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY, DR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE.Laal Blrthd.y
<br />(Yr..)
<br />
<br />6. DATE OF BIRTH (Mo.. Oay. Yr.)
<br />
<br />Sutton, Nebraska
<br />
<br />90
<br />
<br />March 26, 1918
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />508-16-6151
<br />
<br />6a. PLACE OF DEATli
<br />1iQJi.fJJAl.: 0 Inpallanl
<br />
<br />llIIJEB: :Ili Nuraing HomaiLTC 0 Ho.pice Facility
<br />
<br />FACILITY-NAME (II nol inslllulion, glv. slreel and numbar)
<br />
<br />a ERlOulpatianl
<br />
<br />Q Decadentl! Home
<br />
<br />Tiffany Square
<br />
<br />DOCII
<br />
<br />o Othsr (Sp.Cify)
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />
<br />8d. COUNTY OF DEATH
<br />Hall
<br />
<br />Ya. RESIDENCE.STAT~
<br />Nebraska
<br />
<br />!lb. COUNTY
<br />Hall
<br />
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />!XI YES 0 NO
<br />
<br />9d. STREET AND NUMBER
<br />2527 West John St.
<br />lOa. MARITAL STATUS ATTIME OF DEATH IXI Marrlad 0 Na... Marriad
<br />
<br />9f. ZIP CODE
<br />68803
<br />
<br />lOb. NAME OF SPOUSE (First. Mlddlo, L.st, Suffi.)II wifo, givo maidon namo.
<br />
<br />o Married, bul.aporatOd 0 Wldow.d 0 Divorced 0 Unknown
<br />
<br />Lucille Smith
<br />
<br />11. FATHER'S.NAME (First,
<br />William
<br />
<br />Mlddlo,
<br />
<br />Last,
<br />Hurst
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S.NAME (First,
<br />Anna
<br />
<br />Mlddlo,
<br />
<br />Maiden Surname)
<br />Kranz
<br />
<br />13. EVER IN g'ST ~1J!.1~D FO~CES? Giva/dati 01 'a[v!g.11 yeo. 14S.INFORMANT.NAME
<br />(yJ.io~o~u~.)Z/ /1941 11/2 19'D Lucille Hurst
<br />
<br />15. METHOD OF DISPOSITION 16a. EMBALMER.SIGNATURE
<br />o Burl.1 o Donation Not Embalmed
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />16b. liCENSE NO.
<br />
<br />15c. DATE (Mo.. Day, Yr. )
<br />December I, 2008
<br />
<br />STATE
<br />
<br />iXcr.m,"on 0 Entombmant
<br />
<br />l6d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY /TOWN
<br />
<br />o R.mov.1 0 Other (Spacity)
<br />
<br />Westlawn Memorial Park Cremator
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (S"set, City or Town, Sial')
<br />Apfel Funeral Home, 1123 West Second,
<br />
<br />
<br />
<br />Grand
<br />
<br />68801
<br />
<br />1$. ~A.RT I. Enter the ~~.-dlsea$e'S, injuries, Or compllcatlonsuthat directly caused the death. DO NOT enler terminal events such as cardiac arrest,
<br />respiratory arrest, or ~entrlcl,llar fibrillation without showing the eUology. DO NOT ABBREVIATE. Enter only one cause On a line. Add additlonalllne$lf necessary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDiATE CAUSE:
<br />
<br />onsallo d.ath
<br />
<br />~..~; f.(l !A.4-?1J...{ y
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />;::~ lutt...f._
<br />
<br />'1 uJK
<br />
<br />IMMEDIATE CAU8E (Final
<br />dl..... oroondlllon ,""ulllng
<br />In_)
<br />
<br />8oquonllallylIaloondllfona,it (b) .... ;j .A!..tAA.M-tJP1J.
<br />anY,leodlnglothocau..it8led -D-UETO~tRASACONSEQUENCE OF: .
<br />on line e.
<br />Enfortha UNDERLYING CAUSE
<br />(dl..... or InJu'Ythotlnltiehod (c)
<br />tha_nts ..aultlng In death)
<br />WI'
<br />
<br />onset to death
<br />
<br />'3a/J('
<br />
<br />onset to death
<br />
<br />C tI MJA(Lt;- A S,!J ( J!A?'1eJAl
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />
<br />uJl(
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />16. PART II. OTHER SIGNIFICANT CONDITIDNS.Conditlons contributing to Iha death but nol resulting In Ihs underlying caus. given In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />o YES ~O
<br />
<br />""/)t/l1Wll~
<br />
<br />20. IF FEMALE: 21a. MANNER OF DEATH 21b.IFTRANSPORTATlON INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />CJ Not pregnant wIthin past year ~ral D Homicide 0 Driver/Operator
<br />o pragnant a' tlma of d.at~ a AccidonlD P.ndlng Inve'ligation 0 P....ng.r
<br />o NOI pr.gnant, but pregnant within 42 d.ys 01 death 0 Sulcld. 0 Could not b. dal.,mln.d 0 Pede,trian 21d. WERE AUTOPSY FINDINGS AVAILABLETO
<br />o Not pragnant, but pregn.nt 43 dSy' to 1 year balor. d..lh 0 Olh.r (Sp.cify) COMPLETE CAUSE OF DeATH?
<br />o Unknown If pr.gnant within Ihe past y.ar 0 YES 0 NO
<br />22.. DA~.E_:: INJURY (Mo.. Day, Yr.) -..~t.2:.. TIME OF INJUR: 22C. PLACE OF INJURY.AI homa, Isrm, strael, laclory, office building, conslructlon sila, atc. (Spaclty)
<br />
<br />
<br />22d.INJURY AT WORK? 22.. DESCRIBE HOW INJURY OCCURRED
<br />
<br />DYES
<br />
<br />,r;1 N 0
<br />
<br />o YES 0 NO
<br />
<br />22t. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CrTYlTOWN
<br />
<br />SOOE
<br />
<br />ZIP CODE
<br />
<br />24a. DATE SIGNED (Mo.. Dsy. Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />Z>-
<br />~~!!!
<br />~iila:
<br />,j~~
<br />E">-Z
<br />015....0
<br />]Z~
<br />~~~
<br />
<br />m
<br />
<br />23c. TIME OF D~ATH
<br />0450
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo.. D.y, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />248. On the basis of examination and/or investigation, in my opinion death OCCUrred at
<br />tha lima, date .nd pl.c. .nd due 10 tha cau'a(s) Slal.d. (Slgnetu,e .nd Titla) "
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />o YES _~ 0 PROBABLY.. ~.. UNKNOWN 0 YES NOI Ap~Hc.bl.1I25S is NO 0 YES NO
<br />27. NAME, TITLE AND ADDRESS OF C~RTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Prlnl)
<br />David Colan M.D. 729 North Custer Grand Island, NE. 68803
<br />
<br />26.. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo.. Dsy, Yr.)
<br />
<br />DEe '. 4. 2008
<br />"
<br />
<br />HHS.61111D3 (55061)
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