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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANO HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECCOAD ON F11.1c WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATLgTk'4 3`FC iA+H/CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE ^"`1T
<br />FEB 2 4 2f 105 :- TANLEY S COOPER
<br />LINCOLN, NEBRASKA 20050179 �fEAtiH AND HUMAN SER ViCES
<br />STATE OF NEBRASKA- DEPARTMENT OFICOTF []F DE4TH SERVICES FINANCE AND SUPPORT- n1 573
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />2. SEX
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />Maxine Marie Hawes
<br />Female
<br />February 9, 2005
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE -Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />MOS.
<br />DAYS
<br />HouRS
<br />MINS.
<br />Kenesaw, Nebraska
<br />(Yrs.) 71
<br />June 24, 1933
<br />7. SOCIAL SECURITY NUMBER
<br />Be. PLACE OF DEATH
<br />505 -38 -5612
<br />HOSPITAL: ❑ Inpatient ❑ Nursing Home/LTC ❑ Hospice Facility
<br />❑ ER /Outpatient Decedent's Home
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />1504 Grand Island Ave.
<br />❑ DO4 ❑ Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (include Zip Code)
<br />Bd. COUNTY OF DEATH
<br />Grand Island 68803
<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 />1504 Grand. Island Ave.
<br />1 1
<br />68803
<br />QF YES ❑ NO
<br />Married ❑Never Married tOb.
<br />10a. MARITAL STATUS AT TIME OF DEATH
<br />NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. ,
<br />Wayne N. Hawes
<br />❑Married, but separated ❑Widowed ❑Divorced ❑Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Lloyd (NMI) Goudy
<br />Goldie (NMI) Maxfield
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes.
<br />14a. INFORMANT -NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />No
<br />Wayne N. Hawes
<br />Husband
<br />(Yes, no, or unk.)
<br />15. METHOD OF DISPOSITION
<br />16a. EMBALMER -SIG TURE
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr. )
<br />MI ❑
<br />r - �
<br />1D.
<br />February 12, 2005
<br />Burial Donation
<br />16J . CEMETERY, CREMATOhY OR OTHER LOCATION CITY/TOWN STATE
<br />❑ Cremation ❑ Entombment
<br />Westlawn Memorial Park Cemetery, Grand Island, Nebraska
<br />11 Removal ❑ Other (Specify)
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code
<br />Kleine Funeral Home, 3213 W North Front St., Grand Island, NE 68803
<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 arrest, I APPROXIMATE INTERVAL
<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. t
<br />' IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final (a) I
<br />disease or condition resulting DUETO,ORASACONSEQUEN E I onset to death
<br />In death)
<br />I
<br />Sequentially list conditions, 11 (b) 9
<br />;.
<br />any, leading to the cause listed DUE T0, OR AS A CONSEQUENCE F: - I onset to death
<br />on line a. t
<br />Enterthe UNDERLYING CAUSE
<br />(disease or injury that initiated (c)
<br />(•,
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST
<br />(d)
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />�il aY $]
<br />❑YES NO
<br />2200IIFFFEMALE: 21
<br />a. MA AOFDEAT 21
<br />b. IF TRANSPORTATION INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />IQ Not pregnant within past year
<br />atural ❑ Homicide
<br />❑ Driver /Operator
<br />❑ 0
<br />❑ Pregnant at time of death
<br />❑ Accident❑ Pending Investigation
<br />❑ Passenger
<br />YES JI/N
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Suicide ❑ Could not be determined
<br />❑ Pedestrian
<br />' ❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />O Other (Specify)
<br />COMPLETE CAUSE OF EATH?
<br />• ❑ Unknown if pregnant within the past year
<br />_.
<br />❑ YES W0
<br />--
<br />22a. DIATE OF INJU RY (Mo., Day, Yr.)
<br />22c. PLA CE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />T!VV
<br />22d. INJURY AT WORK?
<br />jr,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />'. ,.
<br />❑YES
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CrrY/rOWN STATE ZIP CODE
<br />'
<br />23a. DATE OF DEATH (Mo., Day, Yr.) Z >, 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIME OF DEATH
<br />•'.,
<br />s
<br />U
<br />=
<br />9N0
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />23b. DATE SI Day, Yr. 23c.TIME OF DEATH c a Gy r
<br />J
<br />rn0
<br />J fll
<br />M E !A
<br />o
<br />23d. T the b st of my know a e, d at ccurred at the time, date and place ° w Z 24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />Title)
<br />i d due to the cause(s) s t Signature and Title) ♦ ¢ U the time, date and place and due to the cause(s) stated. (Signature and
<br />Q
<br />/ ~ U `O
<br />�?
<br />25. DIDTOBACCO U L^Q TRIBUTET HE -ATM?
<br />26 AS bFfGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />.
<br />26b. WAS CONSENT GRANTED?
<br />L) YES NO C3 PR ABLY LINK N
<br />❑ YES ❑ NO
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />a;
<br />27. NAME, TITLE A DADDRESS CER F (PH N, CORONER'S
<br />(- '
<br />PHYSICIAN R COUNTY ATTORNEY) (Type or Print)
<br />'
<br />1 ��% Elpidionestor Iloreta, M.D.
<br />V
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />/&Xk i �*�'
<br />FEB 16
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