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<br />
<br />STATE OF NEBRASKA .. . .>i
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEA#.TH AND HUMAN' SERVicES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL R~-t:w"F1LE WitH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSTJCiifSECTToN,cWfflCH IS
<br />
<br />:::;::~~:::::;TORY FOR VITAL RECORDS. jvtf};#:f~-~.~~
<br />NOV 22 2006 }J'7"":lJiANLEY.oSfcob~#
<br />AS$JsT-MJTSiATEREtilSTHAti
<br />LINCOLN, NEBRASKA 2 0 0 9 0 2 4 91 HEALtH ANI( ~-"=~.Z~~~#VtCES
<br />
<br />.,
<br />
<br />1. DECEDENT'S-NAME (Flrsl,
<br />Floyd
<br />
<br />~:=, ~ ~..:-:~if:.~..
<br />......- -.-., ~---:=::-
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES-FINANti[';b,ND SUPPORT
<br />CERTIFICATE QF DEATH ..325] 0
<br />la.I, Suffix) 2, SEX 3, DATE OF DEATH (Mo" Day, vr.!
<br />Towne Male November 15, 2006
<br />
<br />-:;~-=-
<br />
<br />.'._.u. .. ':=t1",' ~7". ....
<br />
<br />
<br />Middle,
<br />Abraham
<br />
<br />South Dakota
<br />
<br />5a. AGE.laOl Blrlhday 5b. UNDER 1 VEAR
<br />(Vr..) MOS. DAVS
<br />70
<br />
<br />5e. UND~R , DAV
<br />-- ~,-
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH ("10" Day, Yr.)
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />February 12, 1936
<br />
<br />8b. FACILlTY-NAM~ (If nol In.titullon, give .Ireel and number)
<br />
<br />Ia PlACE OF DEATH
<br />HQSflIAJ.: :II: Inpatient QD:JEB: 0 Nurolng HomolLTC 0 Ho.plee Faclllly
<br />f.) ~R10Ulpallanl 0 Decedent'. Home
<br />
<br />o [l)\ 0 Olher (SpeelfyL
<br />---
<br />
<br />8d. COUNTY OF DE...TH
<br />Hall
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />504-28-7431
<br />
<br />Saint Francis Medical Center
<br />
<br />8e, CITY OR TOWN OF DE"'TH (Include Zip Code)
<br />Grand Island, 68803
<br />
<br />19b' COU. NTY
<br />Hall
<br />
<br />
<br />91. ZIP CODE
<br />68801
<br />
<br />gg. INSIDE CITY liMITS
<br />Xl WI ;2 NO
<br />
<br />9d. STREET AND NUMBER
<br />721 S. sycamore ST
<br />
<br />lOa. M"'RITAl ST"'TUS ATTIME OF DEATH MMoirled 0 Never Married lOb. NAME OF SPOUSE (FI..t, Mlddle,l.sl, Sulf1x) II wllo, gl'/e maiden name.
<br />ClMarrlad,bul.eparatad OWldowed ODlvoroeJ OUnknown Sandra Eve Stewart
<br />
<br />11. F"'THER'S.NAME (Flr.l:
<br />George
<br />
<br />Middle,
<br />Everett
<br />
<br />Last,
<br />Towne
<br />
<br />Sulflx)
<br />
<br />12. MOTHER'8-NAME (FirSI,
<br />Bertha
<br />
<br />Mlddlo,
<br />Alma
<br />
<br />Maiden surname)
<br />Myers
<br />
<br />13, EVER IN U.8. "'RMEO FORCES? Glva daleo of oervleelf yes. 14a.INFORM"'NT-NAME
<br />(Ves, no, or unk.) No Sandra Eve
<br />15. ME-:;:HODOF OISP~OSITION ,..16H )ALMER,SIGNATURE,:Y ,)
<br />HBurlal 0 Dona lion ~ yaf;u .t...L-"</~:-. C...,
<br />o Cremation 0 Enlombmanl 'It . CEMETERV, CREM"'TORY R OTHER lOCATION
<br />
<br />
<br />l4b. RElATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />CITV fTOWN
<br />
<br />16c. DATE (Mo.. Day, Yr.)
<br />Nov 17, 2006
<br />
<br />ST...TE
<br />
<br />16b. liCENSE NO.
<br />1092
<br />
<br />o Removal 0 Olher (Spaelly)
<br />
<br />Cemetery
<br />
<br />Grand Island
<br />
<br />NE
<br />
<br />170. FUNERAL HOME NAME AND M...llING ADDRESS (Slreel, Cify or Town, Stala)
<br />Curran Funeral Chapel 3005 South Locust
<br />
<br />PART L Enler lhe chain of events--dloo..a., Injurl.., or compllcalions--Ihal directly cau.ed Ihe de.t~, DO NOT entar tarmlnalovenl. .uch so cardiac arrest,
<br />re.plralory arrest, or v.nlrlculsr fibrilla lion wlthoutoltowlng Ihe ellology, DO NOT ABBREVIATE. Enl.r only on. cau.. on a line. Add addlllonalIIn..II naoesnry.
<br />
<br />IMMEDI...TE C"'USE:
<br />
<br />on.al to dealh
<br />
<br />IMMEDIATE CAUSE (Fln,'
<br />dl..... or condition r..ulUng
<br />In death)
<br />
<br />(a) CAN C tA___
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />( A AicA..lA- 5
<br />
<br />G Itto.
<br />
<br />on.el to deat~
<br />
<br />Sequenllalty IIsl c.ndltlon.,If
<br />any, leading to the ""use listed
<br />0" IIn. II.
<br />Enterlho UNDERlYING CAUSE
<br />(dl.e,.. or Injury Ihat Initiated
<br />Ihe ev.nts ,."ulllng In death)
<br />l.ASr
<br />
<br />(b)
<br />OUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on..1 to deat~
<br />
<br />(c)
<br />
<br />. DUE TO, DR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />(0)
<br />
<br />o Suicide 0 Could nol be determined
<br />
<br />21b. IFTRANSPORTATION INJURY
<br />o Drlver/Oporalor
<br />
<br />o Paosenger
<br />
<br />o Pede.i,lan
<br />
<br />o Dlher (Specify)
<br />
<br />19. WAS MEDlc...L EXAMINER
<br />OR CORONER CONTACTED?
<br />U YES jil,. NO
<br />21c. WAS"'N AUTOPSV PERFORMED?
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Condition. conlributing to t~. death but nel re.ulting In the underlying csuoe given In PART I.
<br />
<br />Qo) PP""'I
<br />20. IF FEMAlE:
<br />o Not pregnant within past year
<br />o prsgn.nl al lime of do.lh
<br />o NOI pregnanl, but pregoont wllhin 42 day. of dealh
<br />o Not pregnant, but pregnanl 43 day. 10 1 yeor belore dealh
<br />o Unknown II pregnanl within I~e pa.1 year
<br />
<br />II. U/I/UY11JA Y
<br />
<br />/1'1-1~".
<br />
<br />210. MANNER OF DEATH
<br />DlNatural 0 Homicide
<br />
<br />o YES ~NO
<br />
<br />o AccldenlO Pending Inveollgatlon
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAIlABLE TO
<br />COMPlETE CAUSE OF DEATH?
<br />o YES W NO
<br />
<br />o YES 0 NO
<br />
<br />
<br />220. DATE OF INJURY (Mo., Oay, Vr.)
<br />
<br />22b. TIME OF INJURV 22c, PLACE OF INJURY...., hom., farm, olreet, faolory, office building, con.lruellon all., elo. (Spaclly)
<br />m
<br />
<br />22d, INJURY ATWORK7
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT, NO,
<br />
<br />CITYIfOWN
<br />
<br />SWE
<br />
<br />ZIP CODE
<br />
<br />~~
<br />E:!!~
<br />i~o
<br />a.i~~
<br />~~~~
<br />11155
<br />~a::U
<br />815
<br />
<br />25. DID TOBACCO USE CO TRIBUTETOTHEDE",TH? 26a. HAS ORGAN OR TISSUE DON...TlON BEEN CONSIDERED? 25b. WAS CONSENT GR"'NTED?
<br />
<br />DYES V' NO 0 PROBABLY 0 UNKNOWN 0 YES !II NO Not Applie~ble 1125a IS NO._I:J YES !II NO
<br />27, NAME, TiTlE ~~ ADDRESS OF CERTIFIER (PHYSictAN.-CORONER'S PHYSICI...N OR COUNTY ATTORNEY) (Type or Prlnl)
<br />David R. Colan NO 729 N. Custer AV, G~and Island, NE 68803
<br />
<br />24a. D"'TE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />24<. PRONOUNCEO DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basIs of examination and/or investlgallon, III my opinion dealh occurred el
<br />Ihe tlmo, dale and place and due to t~a cau.a(s) otaled. (Signatur. and Tltlo )1'
<br />
<br />28a, REGISTRAR'S SIGNATURE 28b, DATE FilED 8'1 REGISTRAR (Mo., Day, Vr.)
<br />
<br />
<br />NOV ! 1 200
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