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STATE OF NEBRASKA
<br />
<br />WHEN THIS COPY CARR/ES THE RAISED SEAL OF THE NEBRASKA HEAL~'1 AND HUMAN SERVICES
<br />SYSTEM, lT CERTIF'IE3 THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REC.9R~£~L€LLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, V/TAL STATISTLI~$~C~a~H /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. -
<br />DATE OF ISSUANCE - - '>~•;,;= ==
<br />MAR 2 9 zQO~ - -_ ~-~~)>~~.
<br />ASi~ISTAN~ sT~E Ia7Ef~fi-TI~IfAf~
<br />LINCOLN, NEBRASKA HEA~TLfi~ID f'/iJMAN SL~Ri/IeE~
<br />200907431 = -- -- =--
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCL AN6SUPPd r~ r
<br />CERTIFICATE OF DEATH _~~,-....'~
<br />1. DECEDENTS-NAME (First, Middle, Lasl, Suffix) 2. SEX 3. DATE OF DEATH(Mo.,Day,Yr.)
<br />Lilla.an T,. Miller Female March 2s, aoo~ T
<br />4~. CITY AND STATE OR TERRITORY, OR FGREIGN COUNTRY OF BIRTH 5a. AGE•Lest Blrlhday 5b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Dey, Yr.)
<br />(Yrs.) MOS. BAYS HOURS MINS.
<br />Comstock, Nebraska 83 Q5 ].1 1 October 14, 1922
<br />7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />5 0 8 -18 - 9 4 8 3 )i05PITAL: ^ mpatlent 4It1E8: (~ Nursing Hom®/LTC U Hoeplce Facility
<br />Bb. FACILITV•NAME (If not Inalilullon, glue street and number) I ^ ER/Outpetlenl ^ Decadent'sHomo
<br />Cl'.'_ .~..~
<br />w,' Beverly Healthcare Park Place ~ ~ ^Other(Spaclfy) -....
<br />';t~ ~- Bd. COUNTY OF DEATH
<br />8c CITY DR TOWN OF bEATH (Include Zlp Cada)
<br />Grand Island, 68$03 Hall
<br />;~ Ba.RESIDENCE-STATE 8h.000NTY 9c. CITY OR70WN
<br />;,~ Nebraska Hall Grand Island ___
<br />°~ - -- -~- '° 99. APT. NO 9f. ZIP CODE 9g.IN51DECITY LIMITS
<br />~;~- `~ 9d. STREET AND NUMBER 6 8 $ O ~ ~ YES U ND
<br />~" zol~ w. ~.ltn _
<br />7
<br />`.ti{ . 10a. MARITAL STATUS AT TIME OF DEATW ^ Mewled ^ Never Married 10b. NAME OF SPDU5E (Flrsl, Middle, Lasl, Sulllx) 11 wile, glue maiden name.
<br />J ^Marrled.bulseparated ~Wldowe9 ~IDival'red ~7Unknown An~hdn~7 D Mllle~' -
<br />~'-r' ~ Last, Suffix) 12. MOTHER's•NAME (Firs!, Middle, Maiden 5urneme)~
<br />11. FATHER'S•NAMF (First, Middle,
<br />`° Joseph F Lukash Albino E. Parkos
<br />u
<br />13. EVER IN U.S. ARMED FORCES? Glve datasol service If yes. 14a.INFORMANT-NAME 14b. RELATIONSHIP TO DE
<br />(Yes, no, Drunk.) NO TOm Miller Son
<br />15. METHOD OF DISPOSITION 18a. EM r~.M •51 NATO ~7 18b. LICENSE N0. 18c. DATE (Mo., Day, Yr. )
<br />/J ? / Mar 28, 2006
<br />Burial ©Donatlon ,, ~~,. ~ _ 1191 _„ ...._.
<br />' 18d. CEMETERY, CRE RY OR OTHEhI LDCAT~ CITY /TOWN STATE
<br />^Cramatlon ^Enlombment
<br />!--~ ^Remgval ^omer(speany) Westlawn Memorial Park Grand Island NE
<br />na. FUNERAL HOME NAME AND MAILING ADDRESS (51reeU City or Town, Stale)
<br />lrivingston-3ondermann Funeral Home 601 N. Webb Road, Grand Island
<br />•a .CA~U, E~P~;4EATH (ire-~-~`instPUCS1Ct1~9T';` - ~)~.`
<br />11f, PART I. Enter Ihachain of eventa•-diseases, injuries, or eomplleatlona--that dlreetly caused the death. 00 NOT emer terminal events ouch as eerdlae arrest,
<br />/ • resplralnry arrest, or ventricular Ilbrlllalion wllhout showing the atlDlDgy. DO NP7 ABBREVIATE, Enter only one cause on a Ilne. Add addltlonal Ilnes If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE(Flnal (a) `-~`~`'~1r '~-'UmQ
<br />disesaeorconddionresulting DUE TO, ORASA NSEQUENCEOF:
<br />in death)
<br />5equenllally list Condltlons, II (b)
<br />any,leadingtothecausellated DUE T0, OR A5 A CONSEDUENCE OR
<br />on Ilne a.
<br />FntertheUNDERLYINGCAUSE (c)
<br />(disea9e or Injury That Inllleled
<br />the events resulting Indeath) - GUE T0, CR AS A CONSEQUENCE OF:
<br />INST
<br />~. m
<br />f°. 22d.INJURY AT WORK? 122e. DESCRIBE HOW INJURY OCCURRED
<br />176. Zip Code
<br />N 68803
<br />~APPROXIMA7E~INTERVAL
<br />I
<br />I
<br />14~nsel to death
<br />I' `
<br />I
<br />I enact to death
<br />I onset to death
<br />I
<br />I onset tD death
<br />I
<br />I
<br /> -
<br /> PART IL OTHER SIGNIFICANT CONDITIONS-Condltlons
<br />18 con Iblfling tv the death but net resulting In the underlying cause given In PART I. WAS MEDICAL EXAMINER
<br /> .
<br />~~~ `
<br />/ pR CORONER CONTACTED?
<br />r ~
<br />~, ^ YES ~ NO ...~
<br />~ .IF FEMALE: .
<br />;IQe.MANNEROFDEATH -
<br />216. IF7RANSPORTATIONINJURY 29'c.WASANAUTOPSYPERFORMED7
<br />/,
<br />,. ~_~_ of pregnant wlthln pass year / ~ Natural ^ Homlclde ^ Driver/Operator
<br />n
<br />^ ^ YES (~ ND
<br />~'
<br />li
<br />i
<br />I
<br />g
<br />^ ger
<br />Passe
<br /> ^ Pregnant at time of death on
<br />ga
<br />ng
<br />nves
<br />^ Accidant
<br />Pend
<br />^Pedeslrlan _
<br />
<br />a
<br />^ Nol pregnaN, but pregnant wlthln 42 days of death
<br />^ Suicide ^ Could not be determined
<br />
<br />^Olher(Specily) 21d.WEREAUTOPSYFINDINGSAVAILABLETo
<br />
<br />OOMPLETECAUSEOFDEATH?
<br /> ^ Nvl pregnant, but pregnant 43 days to 1 year belore death
<br /> ^ YES ^ NO
<br /> ^ Unknown If pregnant wlthln the past year ,~
<br />v, ,
<br />.- U
<br />
<br />22a. DATE OF INJURY (Mo., Dey, Yr.)
<br />
<br />22b. TIME OF INJURY
<br />
<br />22c. PLACE OF INJURY-Al home,
<br />
<br />farm, etreat, laclory, oltice'bullding; conrtructlon alts, etc. (Specify)
<br />- ^VES rl NO i _. .... ..,..
<br />221.LOCA710NOFINJURY•57REET&NUMBER,APT.NO. CRYlTOWN STATE ZIP CODE
<br />t 23a.OATEOFDEATH (Mo.,Dey,Yr.) z ~ 24a.DA7ESIGNED (Mo.,Day,Yr.) 24b.TIMEDFDEATH Cl'I
<br />a? March 25, 2006 ~'~~ -
<br />~ Yr. 24d.71ME PRONOUNCED DEAD
<br />~ X86. b E SIGNED (Mc., Dsy, Yr.) 23o.TIME OF DEATH } 24c. PRONOUNCED DEAD (Mo., Day, )
<br />/_ ~~~~ m
<br />a j 3 a O(o m
<br />,~ ~ ~ O ~ ~ w ~ ~ 24e. On the heals of examination and/or Investlgalion, in my oplnlon death occurred et
<br />2 .To the hest of my knowledge, death occurred al the Ilme, data and place
<br />nd due In the cause(s) slated. (S~i yna~tur~e and Title) •~ g = o the ttma, date and place and due to the cause(s) slated. (5lgnature and Title) •
<br />_.,, ~ bIDTOBACCD USE CONTRIBUTETOT DEATH? a. HA3 ORGAN OR TISSUEp~(/DONATIDN BEEN CONSIDERED? 2~ WAS CONSENT GRANTED?
<br />.f ^ YE5 NO ^ PROBABLY ^ UNKNOWN O VES 0JJ0 Not Appllcab_I_e if 26e Is ND_ ^ YES ^ NO
<br />27. NAME, TITLE AND ADDRESS DF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) f
<br />Dr. Heather Hockman MD 3016 W. Faidley Ave. Grand Island NE 68803
<br />28a. REGISTRAR'S SIGNATURE ~ ~ 286. DATE FILED BY REGISTRAR (Mo., Oay, Yr.)
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