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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 A TRUE COPY OF THE ORIGINALRECORI7ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />"-ITAINLEY S. COOPER
<br />JAN 21 2005 , ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA 20050134 b HEyA�TFI AND HUMAN SERVICES
<br />f,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />CERTIFICATE OF DEATH n� l n 1 l n 1 P 8 1
<br />28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />o JAN 19 2005
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />2. SEX
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />>�
<br />Donna May Towler
<br />Female
<br />January 13, 2005
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Sa. AGE -Last Birthday
<br />51b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Shelton, Nebraska
<br />(Yrs.) 68
<br />MOS.
<br />DAYS
<br />HouRS
<br />Mfrfs.
<br />September 12, 1936
<br />7, SOCIAL SECURITY NUMBER
<br />8a. PLACE OF DEATH
<br />508 -40 -1343
<br />HOSPITAL: ❑ Inpatient OTHER: ❑Nursing Home /LTC ❑ Hospice Facility
<br />❑ ER /Outpatient M Decedent's Home
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />Home: 1152 S. Greenwich
<br />-
<br />❑ ooa ❑ Other (speoily)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />8d. COUNTY OF DEATH
<br />Grand Island 68801
<br />Hall
<br />9a. RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY OR TOWN
<br />Nebraska
<br />Hall
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />9e. APT. NO
<br />91. ZIP CODE
<br />9g. INSIDE CITY LIMITS
<br />1152 S. Greenwich
<br />68801
<br />YES ❑ NO
<br />1 Ca. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married 10b.
<br />NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />a -
<br />❑ Married, but separated IN Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Frank T. Clark
<br />Lydia Gehring
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes.
<br />_
<br />14a. INFORMANT -NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />(Yes, no, orunk.) No
<br />Rodney Towler
<br />Son
<br />15. METHOD OF DISPOSITION
<br />_
<br />16a. R�'1 r 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr. )
<br />LXBurial ❑Donation
<br />rALVER-SIGNAT
<br />g� January 17, 2005
<br />cremation L) Entombment
<br />16d.CEMETERY,CREMATO RO HER LOCATION CITY /TOWN STATE
<br />L1 Removal ❑ Other (speciry)
<br />Cameron Cemetery Wood River Nebraska
<br />'`
<br />4�
<br />17br�`
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) . Zip Code
<br />Apfel- Butler - Geddes Funeral Home 1123 West 2nd, Grand Island, NE 68801
<br />tir �gtir ,.
<br />18. PART I. Enter the chain of events -- diseases, injuries, or complications - -that directly caused the death. Do NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />i
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. I
<br />IMMEDIATE CAUSE: onset to death
<br />I
<br />IMMEDIATE CAUSE (Final (a) / -
<br />__
<br />disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />In death)
<br />I
<br />Sequentially list conditions, if (b)
<br />any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that Initiated (c)
<br />the events resulting indeath) DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />LAST
<br />I
<br />(d)
<br />18. PART 11. OTHER SIGNIFICANT CON9ITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />/SF
<br />OR CORONER CONTACTED?
<br />❑ YES U40
<br />�.,
<br />_
<br />20. IF FEMALE:
<br />/Not pregnant within past year
<br />21a.MAN EROFDEATH
<br />Vtural ❑ Homicide
<br />21 b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />❑ Driver /Operator
<br />'.
<br />W.
<br />❑Pregnant at time of death
<br />❑ Accident❑ Pending Investigation
<br />❑Passenger 0 YES NO
<br />�
<br />U Not pregnant, but pregnant within 42 days of death
<br />P 9 P 9 Y
<br />❑Suicide C1 Could not be determined
<br />❑ Pedestrian
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if
<br />❑ Other (Specify) COMPLETE CAUSE OF DEATH?
<br />/0
<br />:.
<br />EEE
<br />pregnant within the past year - _
<br />❑ YES t ^�'n1
<br />- -- -
<br />•V
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />-- - - --
<br />22c. PLACE OFINJURY -Al home, (arm, street, factory, office building, construction site, etc. (Specify)
<br />m
<br />m
<br />22d.INJURYATWORK?
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ N�
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIPCODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) Z > 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />a� January 13, 2005 au¢ m
<br />�.
<br />z y > 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH m k 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />'am
<br />Eaj n 13 2005 5:1.5a m EPrz m 0 M
<br />u c oyl-O
<br />23d. To the best of my knowledge, death occurred at the time, dale and place a w Z 24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />�'
<br />and due to the ca(A s),stat9d. (Signature and Title) T p O the time, date and place and due to the cause(s) stated. (Signature and Title) 7
<br />/
<br />f- Q..,.. F O U
<br />`o
<br />U
<br />25. DIDTOBP,CtO USE CON R18UTE TOTHE DEATH?
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />L) YES U NO_ ❑ PROBABLY © UNKNOWN
<br />❑ YES O-NO
<br />Not Applicable if 26a a NO ❑ YES ❑ NO
<br />2Z ,TIT
<br />NAMELE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Jane McDonald M.D. 800 Alpha. Ave. Gran Island, NF 68803
<br />28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />o JAN 19 2005
<br />
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