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<br /> STATE OF NEBRASKA
<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, VITAL STATISTICS SE WN,-WHICJ(S
<br /> THE LEGAL DEPOSITORY FOR VITAL RECORDS. T
<br /> DATE OF ISSUANCE y, -
<br /> OEC 0 Y 2005 AKEY& OXWEIf-
<br /> 200902517 ASSISTANT .STA EA&MAA
<br /> LINCOLN, NEBRASKA HEALTH AlWhUMAN SE140 C -
<br /> 7 -7-
<br /> 7- w T
<br /> STATE OF NEBRASKA-DEPARTMENTOF HEALTH AND HUMAN SERVICES FINAN,CI
<br /> CERTIFICATE OF DEATH.- 158
<br /> 1. DECEDENT'S-NAME (First, Middle, Last,
<br /> suffix) 2. SEX
<br /> LQ-Qt_a -.I 3. DATE OF DEATH (MO., Day, Yr.)
<br /> ...~e,~Ila.y-i-~_.
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 6a. AGE-Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Dey' Yr.)
<br /> Long Pine, Nebraska (Yrs.) 80 MOS. DAYS HOURS MINS.
<br /> T..1 y ZO, 1925
<br /> 7. SOCIAL SECURITY NUMBER
<br /> 506-22-8634 Ba. PLACE OF DEATH ~yt -
<br /> - HOSPITAL: ❑ Inpatient ME : IN NursinbHome/LTC ❑HospiceFacility
<br /> 8b. FACILITY-NAME (If not institution, give street and number)
<br /> ❑ ER/Outpatient Q Oecedent'sHome
<br /> Tiffany Square ❑ OaA
<br /> ❑ Other (Specify)_
<br /> 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br /> "`I;' Bd.000NTYOF DEATH
<br /> Grand Island 68803 9c CITY OR TOWN Hall
<br /> 9e. RESIDENCE-STATE 96.000NTV
<br /> .
<br /> Nebraska Hall Grand Island
<br /> 9d. STREET AND NUMBER
<br /> 34 2 3 E. S e e d l i n g M l l e Road 9e. APT. NO 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 10a. MARITAL STATUS ATTIME OF DEATH DI YES 0 NO
<br /> Married ❑ Never Married IOb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br /> Q Married, but separated Q Widowed Q Divorced Q Unknown
<br /> _ Dale Davis
<br /> 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S•NAME (First, Middle,
<br /> Albert Eugene Kesselhuth Meldensurname)
<br /> 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. 14a. INFORMANT-NAME N e~ i t a Mae -
<br /> (Yes, no, or unk.) N d 14b. RELATIONSHIP TO DECEDENT
<br /> Dale Davis husband
<br /> 15. METHOD OF DISPOSITION 16a. BALMER•S~AT :ffftt: 18c. PATE (Mo., Day. Yr. )
<br /> Burial ❑ Donation
<br /> ❑ Cremation ❑ Entombment 16d. CEME RY, CREMATORY OTHER LOCATION - Z
<br /> _ CITY /TOWN STATE
<br /> x' ❑ Removal ❑ Other (Specify)
<br /> 1 _ . , - iew.• Cemete_ rv Lon brask
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City orTOwn, State) .
<br /> All Faiths Funeral Home 2929 S. Locust St. Grand I. 1 17b.zlpCode
<br /> 88
<br /> 18. PART I. Enter the a aln ol•pvenis--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br /> respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional lines If necessary. I.
<br /> IMMEDIATE CAUSE:
<br /> ~ onset to death
<br /> IMMEDIATE CAUSE (Final r
<br /> disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF:
<br /> In death)
<br /> I onset to death
<br /> ' Sequentially list conditions, if (b) I
<br /> any, leading to the cause listed All TO, OR AS A CONSEQUENCE OF:
<br /> } lh on line a. onset to death
<br /> _ Enterthe UNDERLYING CAUSE
<br /> (disease or Injury that initiated (e)
<br /> the events resulting In death)
<br /> _ DUE TO, OR AS A CONSEQUENCE OF
<br /> LAST
<br /> I onset to death
<br /> (d)
<br /> 18, PART 11 OTHER SIGNIFICANT CONDITIONS•Conditlvns contributing to the death but not resulting In the underlying cause given In PART I.
<br /> Q 19. WAS MEDICAL EXAMINER
<br /> ©1 i OR CORONER CONTACTED?
<br /> 20. IF FEMALE U YES X NO
<br /> 21a.MANNER OFDEATH 21 b. IF TRANSPORTATION INJURY 21c,WASANAUTOPSY PERFORMED?
<br /> Not pregnant within past year Natural ❑ Homicide ❑ Orlvar/Operator
<br /> Q Pregnant at time of death Q Accident0 Pending Investigation Q Passenger ❑ YES J°1 NO
<br /> U Not pregnant, but pregnant within 42 days of death ❑ Pedestrian
<br /> C] Not pregnant, but pregnant 43 days to 1 year balers death 0 Suicide Q Could not be determined 21 d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br /> ❑ Other (Specify)
<br /> COMPLETE 1 YES ❑CAUSEONOEATH?
<br /> - ❑ Unknown if pregnant within the past year ❑
<br /> - I YES ND
<br /> 22a. DATE OF INJURY (Mo., pay, n.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, office building, construction site, etc. (Specify)
<br /> In
<br /> 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br /> Q YES ❑ NO
<br /> 22f. LOCATION OF INJURY • STREET & NUMBER, APT. NO, CITY/TOWN
<br /> ST'S ZIP CODE
<br /> 23a. PATE OF DEATH (Mo., Day, Yr.)
<br /> w 24e.DATE SIGNED (Mo.,Day, Yr.) 24b.71ME0FbEATH
<br /> November 1 _
<br /> p u _.2 a = rn
<br /> $ a 23 ,PATE SIGNED (Mo., Dey, Yr.) 23c, TIME OF DEATH lip
<br /> r~ 0 L- '7 ew s-- 1 D . 1 O an iq J 24c. PRONOUNCED DEAD (Mo., Dey, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> :d 23d. To the best of my knowledge, death occurred at the time, date and lace 3 cc o f71 E -0 o and duet I the cause(s) staled. (Signature and Title) • p _ 24e. On the basis of examination and/or Investigation, in my opinion death occurred at
<br /> the time, data and place and due to the cause(s) stated. (Signature and Title)
<br /> BY Q
<br /> 25. DIDTOSACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br /> YES ❑ NO V PROBABLY a UNKNOWN Q YES
<br /> 27.NAME, TITLE ANDADDRESS OFCER7IFIER(PHYSICIAN,CORONER'S PHYSICIAN OR COUNTY ATTORNEY Not Applicable If 26a is NO ❑YES ❑NO
<br /> Richard M. Fruehl'ng M,D 2116 W Fridley pArvre). Grand Island, NE 68803
<br /> 28a. REGISTRAR'S SIGNATURE
<br /> 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> NOV 2 8 2005
<br />
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