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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKq„DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR .1/,ITRL R~c~ftla5;.
<br />DATE OF ISSUANCE /~~~ ;., ''w
<br />BAR ~~ 20.9 2 0 o s o c s o 1 • .~~ANLCY S. 0001~R' . ~'
<br />ASSISTANT ST~4TE REGISTRAR
<br />-DEPAR~IHVT 4>7F MEALY;H A/Vb
<br />LINCOLN, NEBRASKA. r`IIJMA~1 SE"I~,V,~C,ES ~ .
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<br />~~' STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND'~UPPQ,I~
<br />CERTIFICATE OF DEATH ~ ~ lJ"~', 2~~ 3
<br />- 1..DECEDENT'S-NAME (Firer, Middle, Lest, Sufflx) 2. SEX 3. DATE pF DEATH (Mo., Day, Yr.)
<br /> Phyllis Cvrine Campbell Female March 9, 2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY tlF BIRTH 5a. AGE•La6t Birthday 5b. UNDER 1 YEAR
<br />' 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr,)
<br /> (Yrs.) MOS~ DAYS HOURS MINS.
<br /> Grand Island, Nebraska $p April 21, 1928
<br /> 7. SOCIAL SECURITY NUMBER ea. PLACE OF DEATH
<br />~.° 506-28-9902 HOSPITAL; ^ Inpatient gTMCCr $] NuBingHome/LTC ^HospicaFacility
<br /> Bb. FACILITY-NAME (II not Inatitutlon, give street and number)
<br />^ ER/Outpatient ^ Decedent's Home
<br /> Wedgewood Care Center
<br /> ^ m,, C70ther(Speciry)
<br /> 8c. CITY OR TOWN OF DEATH (Include Zip Dode) -~ 8d. CpuNTV OF DEATH
<br /> Grand Island 68803 Hall
<br />., „i; 9a.RE31DENCE•STATE Bb.000N7Y BF CITY OR TOWN
<br /> • --• Nebraska
<br />~._ Hall ~ -- Gx'and Tsland
<br /> 8d. STREET ANDNuMBER 9e. APT. NO 91. ZIP CODE 9g. INSIDE CITY LIMITS
<br />`~, 923 West 9th St. 68801 >~ YES ^ No
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<br />y 10a. MARITAL STATUS AT TIME OF DEATH ^ Married ~ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Sufflx) II wife, glue melden name.
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<br />c ^ Merrled, but separated ^ Widowed ^ pivorced ^ Unknown
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<br />11. FATHBR'S-NAME (First, Middle, Last, Sufllx) _._ _.~..
<br />t2. MOTHER'S•NAME (Flrat, Middle, Maiden 6urname)
<br />}°'; Clarence Campbell Winn~.e Ai].lon
<br />~~,;~~ 13. EVER IN U,S. ARMED FORCE51 Give dates of service if yes. 14e.INFORMgNT-NAME -- 146. RBLATIONSHIP 70 bECEDENT
<br />., (Yes;nv,orunk.) No Shirley McKinne
<br />y Sister
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<br />15. METHOD OP DISPOSITION 16a. E ALMER-SIGNATURE 166. LICENSE N0. 18C. DATE (MO., Day, YL )
<br /> WBufal ^Donation ~ (;>~ c~i,' ~~' i 3~,~'j March 13, 2009
<br /> ^ Cremation ^ Entam6ment 16d. CEMETERY, CREMATORY OR 0TH LOCATION CITY /TOWN STATE
<br /> QRemoval ^Other(Specify) Westlawn Memorial Park Cemetery, Grand Island, NE
<br /> 17fl. FUNERAL HOME NAME ANb MAILING ADDRESS (Stras6 Clty or Town, State) 17b. Zlp Code
<br /> A fel Funeral
<br />Home, 1123 West Second Grand Island, NE 68$01
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<br /> 18. PAR71. Enter the chain of events••dlseaeas, Injuries, orcompllcetions••tnatdirectly caused the death. DO NOT enter rerminal events such as cardiac arrest, APPROXIMATE INTERVAL
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<br /> respiratory arrest, pr ventricular }i6rillativn without showing the etiology. p0 NOT ABBREVIATE. Enter only one cause on a line. Add addiUpnal lines If necessary. I
<br /> IMMEDIATE CA S
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<br />i pose
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<br />IMMBOIATECAUSE(Flnel •.._(fl)_•u-~W/~ (~Q' ` C ~ ~„
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<br />dle~aeorcondltlpnresulting pUETO,ORASACON UENCEtlF: I Cn991to th
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<br /> Saqumtlally llat Candltlana, if (b)
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<br />• pny, leading to the CeUBa llated
<br />pl1E TO, OR ASACONSEDUENCE OF'
<br />~ I onset to death
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<br />Enter the UNDEALVING CAUSE
<br /> (dleeeseorlnjurymatinlttamd (C) I
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<br /> me event~reeUltinginde~th) bUETO,tlRASACONSEQUENCEOF: onset to death
<br /> LAST
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<br /> 13. PART II, OTHER SIGNIFICANT CONDITIONS•Conditipns cpntributing tp the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br />_;%, ':. ... _ _
<br />~ _ ^YE5 ^ NO
<br />°~; 2D. IF FEMALE: 21fl. MANNER OF DEATH 21 b.IF TRANSPORTATIONINJURY 21c. WA3 AN AUTOPSY PERFORMED?
<br />L~'~;? ^ Not pregnant within past year Q Natural 0 Homiolda b Driver/Operator
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<br />V ^ Pregnant at time of death ^ Accident^ Pending Investigatlpn ^ Passenger YES
<br />NO
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<br />^ Nol re nant, but re nant wlthln 42 de s of death
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<br />^5uicitle ^Cpuldnptbedetermined
<br />^ Pedestrlen ,
<br />.........-
<br />21d.WEREAUTOPSYFINDINGSAVAItABLETO
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<br />`17q- ^ Not pregnant, but pregnant 43 days tp 1 year before death ^ other (Spaclfy) COMPLBTE CAUSE OF DEATH?
<br />~• 0 Unknown it pregnant wlthln the peat year ,•,,,_~_ 0 YE5 ~ NO
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<br />22e. BATE OF INJURY (Mp., Ddy, Yf.) 22b. TIME OF INJURY 22C. PLACE OF INJURY-At home, farm, street, factory, office bWlding, CpnatruCtlpn alts, etc, (Spaclfy)
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<br />':!°};. 22d.INJURYATWORK7 22e.bE5CRIBEHOWINJURV000URRED
<br /> ^ VES ^ NO
<br /> 22f.LOCATIONOFINJURY•STREET&NUMeER,APT.NO. CIN/TOWN STATE ZIPCpbE
<br />
<br />-.. 23a. DAT F EAT (M pay, Yr.) $~ 24a. DATE SIGNED (Mo., Da
<br />y, Yc)
<br />246.TIME OF pEATH
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<br /> = 23b, TE GNED ~,~,Yr.) 23c.TIMEOFDEATH _
<br />24c.PRONOUNCEDbEAD(MO„Day,Yr.) 24d.71MEPRONDUNCEDDEAD
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<br />ast kn wledge, death Occurred at the time, date and place
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<br />i 24e. On the basis of examination and(or Investigatlpn, In my opinlpn deatn occurred at
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<br />fated. (
<br />gnat and T lna lime, dale end place and due tv the cause(s) stated. (SlgnaturB and Title)
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<br /> 25. DIDTtl8A000 CONTRIBUT OTHE DEATH? 26e. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 286. WAS CONSENT GRANTED?
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<br />^ VES ^ NO PROBABLY ^ UNKNOWN Q YE5
<br />~ NO Not Applicable if 26a i9 NO ^ YES yq NO
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<br />27.NAME,TI7LEANDAbb ES OF CERTIFIER (PHYSICIAN,CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type orprlnt)
<br /> Travis Hageman M.A. 729 N. C star Ave., Grand Island, NE 68803
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., bey, Yr,)
<br />I ~aa 1 ~ 2aos
<br />LOT FIVE (5), BLOCK I~f'YNETEEN (19), FAIRVIEW PARK ADDITION
<br />TO THE CITY OF GRAND ISLAND, HALL COUNTY, NEBRASKA
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<br />HHS-81 11!03 15506 1 1
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