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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 TRUE COPY OF THE ORIGINAL RECOB00WFILE-WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL S7ATISTICS_A*Tz0W,_ twcwls
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />OFTAINLEY.i_ZVOPER
<br />FEB 0 1 2005 ASSISTAW-.STATE REOISTPAR
<br />LINCOLN, NEBRASKA 200501049 HEALIW . �IUM W SOMCIES
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />If'9:PTIl1:l AC r%CA'ru nr, nnr.Q7
<br />1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2.
<br />SEX
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />- Milton George Galliart
<br />Male
<br />January 19, 2005
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Sa. AGE-Last Birthday
<br />5b. UNDER I YEAR 5c,
<br />UNDER I DAY
<br />6, DATE OF BIRTH (Mo., Day, Yr.)
<br />MOS.
<br />DAYS HOURSTIMINS
<br />Ellinwood, Kansas
<br />(Yrs.) 90
<br />May 15, 1914
<br />7. SOCIAL SECURITY NUMBER
<br />Its. PLACE OF DEATH
<br />510-03-4125
<br />-
<br />OSAL Inpatient A
<br />H PIT : C3 Nursing Home/LTC L3 Hospice Facility
<br />X01
<br />8b. FACILITY-NAME (If not institution, give street and number)
<br />❑ ER/Outpatient 0 Decedent's Home
<br />Wedgewood Care Center
<br />❑ DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />8d. COUNTY OF DEATH
<br />Grand Island
<br />Hall
<br />ga. RESIDENCE-STATE
<br />9b. COUNTY
<br />9c. CITY OR TOWN
<br />R
<br />Nebraska P�Ha�ll
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />9e. A APT. NO
<br />9f. ZIP CODE
<br />9g. INSIDE CITY LIMITS
<br />822 W. 1st St.
<br />68801
<br />V YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH [Married LI Never Married 10b.
<br />NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />0 marrjied, but separated ❑Widowed ❑Divorced ❑Unknown
<br />Mary Ellen Dittrick
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />12. MOTHER'S-NAME (First, Middle. Maiden Surname)
<br />George Galliart
<br />Amalia Wollert
<br />13. EVER IN U.S, ARMED FORCES? Give dates of service if yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />(Yes,no,orunk.)Yes 05-13-38/02-02-44 Mary Ellen Galliart Wife
<br />15. METHOD OF DISPOSITION l6a-ENViEMER:SIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.
<br />M
<br />3.
<br />Burial C3 Donation 1092 22, 2005
<br />-January
<br />❑ cremation ❑ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />❑ Removal ❑ Other (Specify)
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip' Code
<br />Curran Funeral Chapel 3005 South Locust St. Grand Island, Nebraska 68801
<br />V,
<br />I
<br />18. PART 1. Enter the chain of events-diseases, injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac
<br />ac arrest. APPROXIMATE INTERVAL
<br />4'11
<br />xe
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary.
<br />IMMEDIATECAUSE: onset to death
<br />IMMEDIATE CAUSE (a) Vrc
<br />(Final
<br />-
<br />z
<br />disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />In death)
<br />ff
<br />Sequentially list conditions, If (b)
<br />any, leading to the cause listed DU E TO, OR AS CONSEQUENCE OF:
<br />on line a. I onset to death
<br />C
<br />Enter the UNDERLYING CAUSE
<br />(c) 0
<br />(disease or Injury that Initiated
<br />the In
<br />events resulting DUE TO, OR AS A CONSEQUENCE OF:
<br />death) onset to death
<br />LAST I
<br />Of
<br />18. PART 11, OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />Jt
<br />OR CORONER CONTACTED?
<br />YES ]p NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />21a. MANNEROF DEATH
<br />Natural ❑ Homicide
<br />21 b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ Pregnant at time of death
<br />Cl AccidentL) Pending Investigation
<br />❑ Passenger
<br />L] YES NO
<br />0 Not pregnant, but pregnant within 42 days of death
<br />LISuicide ❑ Could not be determined
<br />EJ Pedestrian
<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />El Not pregnant, but pregnant 43 days to I year before death
<br />❑ Other (Specify)
<br />COMPLETE CAUSE OF DEATH?
<br />❑ Unknown H pregnant within the past year
<br />❑ YES ❑ NO
<br />F.
<br />22a. DATE OF INJURY (Mo., Day, Yr 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, lactory, office building, construction site, etc, (Specify)
<br />m
<br />k"A
<br />22d.INJURYATW 22F
<br />ORK? a.. DESCRIBE HOW INJURY OCCURRED
<br />YES ❑ No NO
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT NO. CRY/TOWN STATE ZIP CODE
<br />239. DATE OF DEATH (Mo., Day, Yr.
<br />z >. 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIME OF DEATH
<br />c1l, 0 4 1� W
<br />nU
<br />ka¢ ITI
<br />23b. DATE SIGNED (Mo. Day, Yr.) 23c.TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />Ea Z
<br />0 11 0
<br />I M z ITI
<br />sU 12
<br />0
<br />ix z 0
<br />To know) Aldge death o! ad
<br />`y at time,
<br />231* a, date and place W 24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br />1 ;4, z
<br />_cZ`er ads (Sign 0
<br />a,d dull too the cause 's and Title) ♦ 0 the lime, date and place and due to the causes stated. (Signature and Title V
<br />0
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH'
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />LIYES ❑ No Ll PROBABLY &UNKNOWN
<br />❑ YES 14 NO
<br />Not Applicable if 26a Is NO ❑ YES SEND
<br />7. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Steven Husen M.D. 2116 W. Faidley AV #400 Grand Island, Nebraska 68803
<br />289. REGISTRARS SIGNATURE r
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />-JAN
<br />2 7 2005
<br />
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