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<br />STATE OF NEBRASKA
<br />
<br />200'0/13 f
<br />
<br />\
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEM1'H-.. "~.'."". '.'~' . 'AN. SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH T~~W9l,fj~f1ltf1. /q1!!N;t OF HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITO,....~;~~..,t~...!. Lt~bfiGO r. '~..;".; J
<br />
<br />DATEOFISSUANCE", . '. .,~ ~
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<br />, ti::A;5SI. f<< $IAtERE~ISTh.IJ.R
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<br />~ \~pMA(V SERVICES : '7, ro"
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AN~,SUP~pRO g-:,~~ '0 0 0 6
<br />CE~IJFI<!ATE OF DEATH ..,., .," .;;
<br />
<br />OCT 0 7 Z008
<br />
<br />LINCOLN~NEBRASKA
<br />
<br />
<br />" DECEDENT'S'NAME (First,
<br />Patrick
<br />
<br />MIOOlo,
<br />David
<br />
<br />Lost,
<br />Evans
<br />
<br />Suffix)
<br />
<br />2, SEX
<br />Male
<br />
<br />3, DATE OF DEATH (Mo.. Day, Yr.)
<br />September 17, 2008
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Seward, Nebraska
<br />
<br />5a, AGE. Last BlrlhOay
<br />(Yrs,)
<br />49
<br />
<br />5b, UNDER 1 YEAR
<br />MOS, DAYS
<br />
<br />
<br />5c, UNDER 1 DAY
<br />MINS,
<br />
<br />6, DATE OF BIRTH (Mo" Day, Yr,)
<br />
<br />October 28, 1958
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />
<br />6a, PLACE OF DEATH
<br />
<br />50 7-80'::.ElD 4
<br />FACILITY-NAME (If not institution, give street and number)
<br />
<br />1:iQ.SflIAl.;
<br />
<br />o Inpatient
<br />
<br />Q]]jOIJ: 0 Nursing Homo/LTC 0 Hoopice FaCility
<br />
<br />o ER/Outpallsnt
<br />
<br />:XI Oecedent's Home
<br />
<br />Home: 904 W. 3rd
<br />
<br />OM
<br />
<br />o Oth.r (Specily)
<br />
<br />6c, CITY OR TOWN DF DEATH (Include Zip Cooo)
<br />Grand Island 68801
<br />
<br />9a,RESIDENCE,STATE -,.,,--~, -19, 9b,COUHNTYall
<br />Nebraska _,1-
<br />9d, STREET AND NUMBER
<br />--"~-'904 W.'. Jrd
<br />
<br />60, COUNTY OF DEATH
<br />Hall
<br />
<br />iCITY OR TOWN
<br />Grand Island
<br />T9;, APT, NO 9f. ZIP CODE
<br />. --68MT~-"
<br />
<br />.geN1:I~~ CITY. LI~ITS .
<br />Xl YES 0 NO
<br />
<br />fOa, MARITAL STATUS ATTIME OF DEATH ~Marriad (.J Nevor Marrloo
<br />
<br />10b,NAME OF SPOUSE (First, Middle, Last, Sulll,) II wilo, glvo molOon nomo,
<br />
<br />o Marrioo, but soparatoo 0 Wldoweo 0 Divorced 0 Unknown
<br />
<br />Daria Michel
<br />
<br />1" FATHER'S,NAME (First, Middle,
<br />Laurence
<br />
<br />Last,
<br />Evans
<br />
<br />SullI,)
<br />
<br />12, MOTHER'S-NAME (First,
<br />Mary
<br />
<br />MidOIO,
<br />
<br />Maloon Surname)
<br />Hans
<br />
<br />la, EVER IN U,S, ARMED FORCES? Givo oates 01 servlco il yos, 14a,INFORMANT,NAME
<br />No Daria Evans
<br />15, METHOD OF DISPOSITION
<br />
<br />DO Burial
<br />
<br />o Donation
<br />
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />16c, DATE (Mo" Doy, Yr,)
<br />
<br />Se.EJ::~.!l!1:!,er 22 , 200
<br />STATE
<br />
<br />o CrematiOr'l a Entombment
<br />
<br />o Ramoval 0 Other (Specify)
<br />
<br />Westlawn Memorial Park Cemetery,
<br />
<br />Grand Island, NE
<br />
<br />PART l. Enter the chain 01 eVP.nI!l--diSeasas. injuries, or complicationsnthat directly caused lhe death, DO NOT &nl8r tarminaJ events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showinQ the etiolOQY, DO NOT ABBREVIATE, Enter only one cause on a line. Add addilionallines if necessary,
<br />
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Stroot, City or Town, Stato)
<br />
<br />Apfel Funeral Home, 1123 West Second,
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onset 10 death
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease Or condition resulting
<br />In doalh)
<br />
<br />w cardiac arrest
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />unknown
<br />
<br />onset to death
<br />
<br />Sequentially listconditicns, if
<br />any,lOOdlng 10 Ihe couoollstao
<br />on line 8.
<br />Enter the UNDERLYING CAUSE
<br />(disease Or injury thllt initiated
<br />'hoovon,o ,""ulling in oeath)
<br />LAST
<br />
<br />(b) __f!1,assive cardiomegaly with mycar~1~J__~~.e.~rtrophy
<br />OUE TO, OR AS A CONSEQUENCE OF;
<br />
<br />unknown
<br />
<br />onset to death
<br />
<br />(e)
<br />
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />onset 10 death
<br />
<br />(d)
<br />
<br />18, PART II. OTHER SIGNIFICANT CONDITIONS.Conoltlons contributing to tho ooath but not ra,ulting in the unoarlylng cau.e given In PART I,
<br />
<br />o Sulcloo 0 Coulo not ba oatarmineo
<br />
<br />21b, IF TRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />o Passenger
<br />
<br />o Pedestrian
<br />
<br />o Othor (Spocify)
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />!Xl YES 0 NO
<br />
<br />21 c, WAS AN AUTOPSY PERFORMED?
<br />
<br />20, IF FEMALE;
<br />
<br />21a, MANNER OF DEATH
<br />~ Natural 0 Homicide
<br />
<br />o Acc:ldenlD Pending Investigation
<br />
<br />JO .y~--. Q NQ-,
<br />
<br />o Nt)1 prl;!gnanl within past year
<br />o Pregnant at time of du.th
<br />o Not prognont, but prognont within 42 dayo of death
<br />o Not pregnant, but pregnant 43 days to 1 year belore death
<br />Q .Unknown if pregnant within the past year
<br />
<br />210, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />(J( YES 0 NO
<br />
<br />22a, DATE OF INJURY (Mo" Day, Yr.)
<br />
<br />22b, TIME OF INJURY 22c, PLACE OF INJURY.At homa,larm, stroel, loctory, ollice builoing, construction Site, .tc, (Specily)
<br />m
<br />
<br />22d INJURYATWORK? ~ESCRIBE HOW INJURY OCCURRED
<br />DYES ONO ____..1
<br />------
<br />22f. LOCATION OF INJURY. STREET & NUMBER, APT. NO, CITYiTOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a, DATE OF DEATH (Mo" Day, Yr,)
<br />
<br />m
<br />
<br />z,.
<br />~g~
<br />H~
<br />D.a.41:~
<br />!l~ti!j
<br />u""z
<br />.8~::>
<br />~a:8
<br />o L
<br />"0
<br />
<br />24a, DATE SIGNED (Mo" Doy, Yr,)
<br />S_e.ptemb~r,_3~ 2008
<br />24c, PRONOUNCED DEAD (Mc" Day, Yr.)
<br />Se tember 17 2008
<br />
<br />24b, TIME OF DEATH
<br />4:05 am
<br />
<br />23b, DATE SIGNED (Mo" Day, Yr.)
<br />
<br />23c, TIME OF DEATH
<br />
<br />24d, TIME PRONOUNCED DEAD
<br />7: 05 a m
<br />
<br />23d, To Ihe baSI of my knowledge. death OCcurred at the time, date and place
<br />and due to the cause(s) staled. (Signature and Tille) ...
<br />
<br />24e, On the basis of examin~~ and/or investigation, in my opinion death occurred at
<br />theti~l.d..~,~,.~ct.P~/ d due to the cause{s) stated. (Signature and Title) ,.
<br />
<br />r-V
<br />
<br />
<br />y
<br />
<br />26, DID TOBACCO USE CONTRIBUTETO THE DEATH?
<br />
<br />26a, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />DYES 0 NO Xl PROBABLY 0 UNKNOWN 0 YES (J( NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN -Oi:i'C'OUNTYATTORNEY) (Type or Print)
<br />Mark J. Youn Hall Count Attorne , 231 S. Locust St.,
<br />
<br />Not Applicabla if 26a is NO 0 YES a NO
<br />
<br />28a, REGISTRAR'S SIGNATURE
<br />
<br />
<br />Grand Island, NE 68801
<br />
<br />26b, DATE FILED BY REGISTRAR (MQ" Day, Yr,)
<br />OCT 3 2008
<br />
<br />HHR.A111IOCl (SSOA1\
<br />
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