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<br />STATE OF NEBRASKA
<br />WHENtTHIS 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..QJ!_-Blii:wrr1:L
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/$TICS SEJltlpN,.wHlCJ1{$-"-,o
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~'. .......................... . .3fi~..- ....~.-~";; .'.'. _""""'" ~.~..' ..-.~-.-.~~.;=...'.....~...:.-..-.:~.
<br />
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE MJD SupniFi!' . .' 0" "'0' . 0 O' 7
<br />
<br />CERTIFICATE OF DEATH' V iJ
<br />-_._-~~.,'~-~,-
<br />
<br />
<br />
<br />5a, AG~.La$1 Birthday 5b. UND~R , Y~AR
<br />.-- -.,.--
<br />(Yrs.) MOS. DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />3. DATE OF DEATH IMo" Day, Yr.)
<br />.._..J',':!I!~IJ!: 2 , 2005
<br />6. DATE OF BIRTH (Mo" Day, Yr,)
<br />
<br />1. DECEDENT'S.NAME IFirst, Middle,
<br />_______._____H?rry___ In les
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Last,
<br />Turner
<br />
<br />Sulflx)
<br />
<br />2.SEX
<br />Male
<br />
<br />_____~<'l:~J::'?,... .~~p:ras!<:~____._..
<br />7. SOCIAL SECURITY NUMBf:R
<br />506-40-0669
<br />
<br />88
<br />
<br />i'i?vember 29, 1916
<br />
<br />Be. PLACE OF DEATH
<br />tiQ.SE1IAL: 0 Inpatiant
<br />
<br />QlliEB: iZNurslng Homs/LTC 0 Hospice Facility
<br />
<br />Bb. FACiliTY-NAME IIf not Instllutlon, give street and number)
<br />Veterans Affairs Medical Center
<br />...Q!: an~_]:,~la!ld , NE
<br />Bc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island, NE 68803
<br />
<br />o ER/OUlpetlent
<br />
<br />U Decedant's Home
<br />
<br />UCO\
<br />
<br />o Other(Specify)___._
<br />
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />
<br />Hall
<br />
<br />
<br />91. ZIP CODE
<br />
<br />9g.INSIDE CITY LIMITS
<br />X! YES 0 NO
<br />
<br />9a. RESIDENCE.STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />
<br />9b. COUNTY
<br />
<br />_}?Q2_~'.1\~@El_~. Street 68801
<br />
<br />, Oa. MARITAL STATUS AT TIME OF DEATH X! Marriad 0 Never Married lOb. NAME OF SPOUSE (First, Middle, Lasl, Suffix) II wife, give maidan nama.
<br />
<br />U Marrlad, but saparalad U Wldowad ODlvorcad 0 UnKnown
<br />
<br />Vivian Davis
<br />
<br />1'. FATHER'S.NAME IFirsl,
<br />Harry
<br />
<br />Middle!
<br />D.
<br />
<br />Last, Sulflx)
<br />Turner
<br />
<br />-.1-.---...--'.. ~-,-,..----..----
<br />12. MOTHER'S-NAME (First,
<br />Helen
<br />. .".''''.'-'-'".'~_.~.
<br />
<br />Middle,
<br />
<br />Maldan Surnsme)
<br />Ingles
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />, 3. EVER IN U.S. ARMED FORCES? Give defes of ,arvlca II yas. 14a.INFORMANT.NAME
<br />Vivian Turner
<br />
<br />IYes,no,orunK.) es 2 13L!i2-2113/46
<br />'5. METHOD OF DISPOSITION 16a. EMBALMER.SIGNATURE
<br />o Bu,lal o Donalion Not Embalmed
<br />
<br />, 6b. LICENSE NO.
<br />
<br />, 6c. DATE (Mo., Day, Yr. )
<br />
<br />Xl Cramstlon 0 Entombment
<br />
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY /TOWN
<br />
<br />STATE
<br />
<br />o Removal o Other ISpaclfy) Westlawn Memorial Park
<br />
<br />Grand Island,
<br />
<br />Nebraska
<br />
<br />17a. FUNERAL HOME NAME AND MAiliNG ADDRESS (Street, City or Town, Slata)
<br />Apfel-Butler-Geddes Funeral Home
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />PART l. Enter Ihe chain of BVBntsndisBasBs, injuries, or compllcatlons--Ihal dlreotly caused the death. DO NOT enter termInal events such as cardIac arrest,
<br />raspiratory arrest, or vent,icular fibrillation without showing the eliology. DO NOT ABBREVIATE. Enter only one csuse on allna. Add additlonalllnas if n.c.ssary.
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl.e.se or conditIon resulting
<br />In desth)
<br />
<br />(a) RespiratQ.IT___,
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I
<br />I
<br />
<br />, onsal to dealh
<br />I
<br />
<br />I few weeks
<br />_L:'._..__ __. ., . _ n._________
<br />I onset to death
<br />I
<br />I
<br />I fp.w J[p.arR
<br />I onsalto aaath
<br />I
<br />I
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />Sequentlslly IIs1 conditions, il
<br />any,leadlng 10 the cause listed
<br />on lines.
<br />Enlerthe UNDERLYING CAUSE
<br />(dl.esse or Inlury thst Inltlsled
<br />the events resulting In desth)
<br />lAST
<br />
<br />Ib) Osteoporosi s, arthri tis adYance.cL.~...
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />._~cl_gQ:r;:OI1~~Y Artery Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />o AccidentO Pandlng Investigation
<br />U Sulcida 0 Could not be determined
<br />
<br />2'b.IFTRANSPORTATION INJURY
<br />o Driver/Operalor
<br />
<br />o Passenger
<br />
<br />o Pedestrian
<br />
<br />o Other (Speclly)
<br />
<br />I onsat to death
<br />,
<br />,
<br />
<br />
<br />F:~:':;:;;;=-
<br />
<br />
<br />2'c. WAS AN AUTOPSY PERFORMED?
<br />
<br />Id)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS.Condltlons contributing 10 the death but not resulting In the underlying cause given In PART I.
<br />
<br />U Not pregnant within past year
<br />o Pregnanl at time 01 deslh
<br />o Not pregnant, but pregnanl within 42 dsy' of dealh
<br />U Nol pregnanl, but pregnant 43 days to 1 yaar belore death
<br />Q..l"InkROWr:l. i!..prCgA3nt wilhiR-!he-past.;,.'liIa!
<br />
<br />21e.MANNER OF DEATH
<br />~ Nalural 0 Homicide
<br />
<br />DYES
<br />
<br />~NO
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPL.T. CAUSE OF DEATH?
<br />
<br />JJ YF~..
<br />
<br />o NO
<br />
<br />220. DATE OF INJURY IMo., Day, Yr.)
<br />
<br />22b. TIME OF INJURY 220. PLACE OF INJURY-At home, fsrm, street, f.ctory, office building, conslruction olte, eto. (Specify)
<br />rn
<br />
<br />--22d INJURY AT WORK? - 'j22'--D-ESCRIBE HOW INJURY OCCURRED
<br />DYES 0 NO
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITYlrOWN
<br />
<br />SlATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo., Dey, Yr.)
<br />January..J, ...200~._.
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />23c. TIME OF DEATH
<br />4:08 am
<br />
<br />...~~
<br />-"0
<br />lliJja:
<br />I~S~
<br />!i~ti5
<br /><>wZ
<br />.!lZ::>
<br />00
<br />~a:O
<br />811
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To the bost of my know)edg ,death occurred allhe lime, date and place
<br />snd due 10 the ceuse(S))i'ated. ISlgnature and Tille) 'f
<br />
<br />249. On the basis of examination and/or InvestIgation, In my opinion death occurred at
<br />tile time, dote and placa and duato Ihe causers) sleted. ISlgnsture snd Title) 'f
<br />
<br />26b. WAS CONSENT GRANTED?
<br />Nol Applfc.~.b.I~ If 26a Is NO 0 YES 0 NO
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />JAN 6 2005
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