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STATE OF NEBRASKA
<br />~ WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT DF:H~ , Q ~ ~1~~A~F~4VICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH TH~'IN~f3R.4L~C ~MI~~,1DT~a HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY f~biw r ~ R C ~ . ~ r ~ . ; ,
<br />r"~' '~,+ ~ r.
<br />f.
<br />DATE OF ISSUANCE ~+ ,,..,
<br />S'~A,CaILE :.- ., MCA, R r';; ; ~
<br />OCT 2 3 2009. A~~N ~~r~~Sr '~
<br />rr O O ~ O $ sJ Q +~r~R~M~~vr q~ I1EAL~rr,A~~ ~ ; >.
<br />LINCOLN, NEBRASKA M~,INr,'~b1/"$F,,~VIC r "r r,' „`.
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<br />STATE pFNEBRASKA- pEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCErAND SUf~PO~Pf`'
<br />_._. _- CERTIFICATE QF DEATH : Q O 4 9
<br />1. DECEDENT'3•NAME (First, Mlddla, Last, Suttix) 2. SEX 3. DATE OF pEATH (Mc., bay; Yr.)
<br />Maxine June Koefoot Female January 7, 2008
<br />4. C17V AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Se. AGE•Last Birthday 5b. UNDER t YEAR 5c. UNDEq 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Tecumseh, Nebraska (Yrs.) 80 MOS. DAYS HOUR9 MINS.
<br />April 28, ].927
<br />7.50CIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />._..._508.-26--4_Z$2 --_
<br />E.t~Ire~ -- - --... -._..--- -- - - ----
<br />-~- - ~~ ~~ ~ Nureing HomelL7C HosplCe Facility
<br />eb. FACILITY•NAME (If not instltutlon, give street end number)
<br />CI ERlOutpatlent ^ Decedent's Home
<br />St. Francis Skilled Care [( pOq a0ther(Specify)
<br />Sc. CITY OR TOWN pF DEATH pnclude Zlp Coda) Sd. COUNTY tlF DEATH
<br />Grand Island 68803 Hall
<br />9e. RESIDENCE-STATE 9b.000Nry 9c.CI7vORTOWN
<br />Nebraska Hall Grand Island
<br />9d.5TREE7ANb NUMBER 9e. APT. Np 91. ZIP CODE 9q. INSIDE CITY LIMITS
<br />2820 Kingston Circle 68803 ~l YES C] NO
<br />toe. MARITAL STATUS ATTIME OF DEATH ~ Married ^ Never Merrled 1Db. NAME OF SPOUSE (First, Middle, Last, Suttix) II wife, give maiden name.
<br />^Married, but separetatl ^Wldowed ^bivorced ^Unknown Robert Koefoot M.D.
<br />11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br />Cline Seckman Lucile Jobes
<br />13. EVER IN U.S. ARMED FORCEST Give dates cl service if yea. 14a.INFORMgNT•NAME 146. RELATIONSHIP TO DECEDENT
<br />(Yea,nc,~runk.) No Robert KoefootM.D. Husband
<br />15. METHOD OF DISPOSITION 168. EMBA R- IGNATU 18d. LICENSE N/0. 1 i3c. DATE (Ma., bay, Yr. )
<br />~Blldel ^ponetlon ~~!/(~ January 1Q, 200$
<br />^Cremation ^Entombment 78d.CEMETERY,CREMATORY ROTHERLOCATION CITYlTOWN STATE
<br />dRamovel ^Other(Speciry) Tecumseh Cemetery, Tecumseh, Nebraska
<br />17e. FUNERAL HOME NAME AND MAILINp ADDRESS (Street, Clty orTown, State) 17b. Tip Cade
<br />Apfel Funeral Home 1123 West Second, Grand Island, NE. 68801
<br />:~,,
<br />18. PART I. Enter the chain Dj,gyenta••dieeaee6, injuries, w compllcatlona••Ihat dlreetly caused the death. by NOT enter terminal events such as cardiac arrest, APPpOXIMATE INTERVAL
<br />I
<br />respiratory arrest, or ventricular fibrillation without showing the etlalbgy. DO NOT ABBREVIATE. Enter only one cause on a line. Add addltlbnal lines If necessary. I
<br />IMMEDIATE CAUSE: ,'/~~` I onset to death
<br />IMMEDIATE CAUSE (Flnal (a) ~ Z ~ ~ ~ ~ S d (~ ~ ~.J \ ~ I ~
<br />dlseeseorsandtilanresulting pUETO,ORASACONSEQUENCEOF: I or1nrse`ttoloath
<br />In death)
<br />I
<br />eequentlallylmaondltlone,h rol I
<br />- erry,bWingtothdausalleted DUE 70, ORA5ACONSEQUENCEOF: LL I
<br />on Ilne e, I onset to death
<br />Erttwur UNDERLYWG CAUSE
<br />(dlauseerln)urythatlntttated (o) I
<br />theevennlwultinplndeaGl) ~ bUETO,ORA3ACONSEOUENCEOF:
<br />_ 1.A8~ I On6et t0 death
<br />I
<br />(d) I
<br />18. PART II. D7HER 91pNIFICANT CONDITIONS-Conditions cantrlbuting to the death but nol resulting In the underlying cause given In PART t. 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTEDI
<br />- ~ ~ N ~ ^ YES ~Np
<br />20. IF FEMALE: 21a.MANNEROPpEATH 2tb.IFTRANSPORTATIONINJURY 21 c. WAS ANAU70PSYPERFORMED7
<br />~~.Nbt pregnant within past year ~'Neturel [] Hamlclde ^ DrlverlOperetor ~/~~
<br />^Pab6en ^ YES {e.ClO
<br />^ Pregnant at time of death C] Accident^ Panding Inveatlgatlon gar
<br />^ Not pregnant, but pregnant within 42 days of death l^ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />^ Suicide d Could not 6e determined
<br />Not pregnant, but pregnant d3 days to 1 year before death ~ Other (Speclly) COMPLETE CAUSE OF DEATH?
<br />f] Unknown II pregnant wllhln the peat year ^ YE3 ~Q
<br />22a. DATE OF INJURY (Mo., bay, Vc) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, o111ce building, conetructibn site, etc. (Specify)
<br />m __ -
<br />22d.INJURYATWORK7 22e.DESCRIBEHOWINJURY000URRED `
<br />^ YES ^ NO
<br />221. LOCATION OF INJURY • STREET & NUMBER, APT. Np. CITYlfOWN y STATE ZIP CODE
<br />z 23e. DATE OF DEATH (Mo., Dey, Yr.) 24a. DATE SIGNED (Mtl., pay, Yr.) 24b. TIME OF DEATH
<br />~ 236. DATE3IGNED(Mo.,Day,Yr.) 23c.71ME0FDEATN~t111dIlig ~ 24c.PRONOUNCEDDEAD(Mo.,Day,Yr.) 24d.TIMEPRONpUNCEDDEAD
<br />'•" ~ ~ C7 - O'~ - C ado O m
<br />~' " ~ ~ m
<br />23d. To the best of my knowledge, death occurred at the time, date and place ~ u°~i ~ 24e. On the heals of examinatlan endlor investigetlon, in my opinion death occurred et
<br />'~ .~ the cause(s) d. (Signature a d isle) • ,g = ~
<br />.. o e p the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25, bIDTOBACCO USECONTRIBUTETpTHE DEATH? 25e. HAS ORpgN OR TISSUE DONATION BEEN CONSIDEREDT 26b. WAS CONSENT GRANTEb?
<br />^ YES ~ O ^ PROBABLY ^ UNKNOWN ^ YE3 _ Nat Applicable if 28a Is NO ^ VES l~Ntl
<br />27.NAME,TITLEANDADDRES50FCERTIPIER (PHYSICIAN,CORONER'S PHYSICIAN OR COUNTYgTTORNEY) (Type orPrinq
<br />John Cannella M. D. 729 N. Custer Ave., Grand Island, NR, b8803
<br />28a. REGISTRAR'SSIONATURE ,( 284. PATE FILED 8Y REGISTRAR (MO., Day, Yr.)
<br />~\I u• JAN 9 2008
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