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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AAlA~HUt'~#N".S$ERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASK.4~~1jE~AR'~MF~VT,.OF ('1~ALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VI3"AL RE'CDRDS
<br />DATE OF ISSUANCE ,1. .• ~C.J •y ~~y
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<br />ASSISTANT .~s~A'~~' RE'G~5PRAR
<br />DEPAR~I~jEf'~~l' Q~ JLIEALTH"A1~1Q "
<br />LINCOLN, NEBRASKA HUMAN'S~RIlICES. ;' ~'; '
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<br />STATE OFNEBRASKA- DEI'AFiTMENT OF WEALTH AND HUMAN SERVICES FINANCE AND SUP,PbR7 t
<br />CERTIFICATE OF bEATH ° ~ ~~ ~~~~_~~
<br /> t, DECEDENTS-NAME (First, Mlddle, T Last, Suffix) 2. SEX 3. DATE OF DEATH (Mb.,Dey,Yr.)
<br />2009
<br />Male August 2$
<br /> ,
<br />Douglas Junior Lockwood
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE•Last Birthday 5b. UNDEA 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (MO., Day, Yr.)
<br /> (Yrs.) 87 MOS. DAYS Haulas Mws. November 13, 1921
<br /> Kenesaw, Nebraska
<br /> 7. SOCIAL SECURITY NUMBER M 8a. PLACE OF DEATH
<br /> 5 20-16-9031 kL4.5P17AL: ^ Inpatient Q'(~ ~ Nursing Home/LTC ^ Hoeplce Facility
<br /> 8b, FACILITY-NAME (If not Instltutidn, glue Street and number) ^ ERlOutpetlent Q Decedent's Home
<br /> Nebraska Veterans Home ^ ar, ^omar(speclfy) .._-.
<br /> 8C. CITY OR70WN OF DEATH (Include ZIp Code) 8d. COUNTY OF DEATH
<br /> Grand Island 6$$03 Hall -_
<br /> 9a. RESIDENCE-STATE gb.000N7Y gc.CITYOR70WN
<br /> Nebraska Adams Kenesaw
<br />T gd. STREETANbNUMBER ~ _ ~ 8e. APT. NO 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 17575 W. Denman Rd. 68956 ^ vl=_s 3Z1 No
<br /> 10a. MARITAL STATUS AT TIME OF DEATH ail Married ^ Never Married tOb. NAME OF SPOUSE (First, Mlddle, Last, Suffix) If wife, glue maiden name.
<br /> ^Married, but separated ^WldoWed ^DIVOrOad ^Unknown Marjorie Burkhalter
<br />- ~ ~_ _. f
<br />r Mlddle, Last, Sulllx)
<br />11.FATHER'S•NAME (First, ~ 12. MOTHER'S•NAME (First, Middle, Maiden Surname)
<br />,
<br />;~ Caurtland Lockwood Martha ,Kroll
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<br />. EVER IN U.S. ARMED FgRCE57 Glve dales of service II es.
<br />13
<br />4
<br />14a. INFORMANT•NAME 146. RELATIONSHIP TO DECEDENT
<br />
<br />Wife
<br />. `
<br />(Yafi'~ivr~Orunk.)10/7/1942 2/7/19 Marjorie Lockwood
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<br />' 15. METHDD OF DISPOSITION _
<br />,,~~117~
<br />lJrBUrial [J Donation 18a. EMB MER-SIGNATURE 166. LICENSE NO. 18c. DATE (MO., Day, Yr. )
<br />~~ ~30~8 5eptembex 1, 2009
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<br /> ^ Cremation ^ Entombment CITY I TOWN STATE
<br />18d. CEMETER REMATORY OR 0 R LOCATION
<br /> ^Rembval C~Dtner(speafy) Shelton Cemetery, Shelton, Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, State) 17b. Zip Code
<br /> A fel Funeral Home, 1123 West Second, Grand TE11and, NE 68801
<br /> 18. PART I Enter InB ~~ ef,vyeflLq--diseases Injurias,Or r:nmplicativns--that directly caused the death. DO NOT enter terminal events such as cardiac amBBt, APPROXIMATE INTERVAL
<br /> respiratory arrest, or venlridular fi6rilletlon Without showing the atiOlogy. DO NOT ABBREVIATE, Enter Only One cause on a Ilne. Add additional lin9s if nece9aary. I
<br />} I onsettbdeatn
<br />IMMBDIATECAUSE:
<br /> 1~1a7^~7 qY~y may,
<br />l (a) C~~p`•"""1 Art""`3 Dl^a~15~ TJ~l 4it ~. 13 ^".I~ntt~s
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<br /> ne
<br />IMMEDIATE CAU5E(
<br />dleeaeewcondltbnreeultlng pUE TO, OR ASACONSEOUENCE OF; I Onset t0 death
<br /> In d~dt) I
<br />I~rtic Stenosis. ~ ~l ^lonth
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<br />5equentlally liar conditions, If O
<br />_
<br /> _
<br />I Onset tb death
<br />shy, leading tO the Feuae listed DUE TO, OR ASACONSEtlUENCE OF:
<br /> On Ilse p. I
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<br />u FrtertheUNDERLVINGGAUSE I
<br />I 1 TnTeek
<br />d (c) Pneunonia
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<br />(dlaeasedrln)ury
<br />gN events r6autling in death) pUE TO, DR ASACONSEOUENCE OF: I Onset t0 death
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<br />S MEDICAL EXAMINER
<br />;° iS. PART IL OTHER SIGNIFICANT CONDITIONS-CondltlOns contributing to the death but not resulting in the underlying cause given in PART I. 19. WA
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<br />~~ OR CDRONER CONTACTED?
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<br />~` ^ YES ~ NO
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<br />2u, IF FEMALE: 21 a. MANNER OF DEATH 216.IFTRANSPORTATIDNINJURY 21c.WASANAUTDPSVPERFORMED7
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<br />~' ^ DrlyBr/Operator
<br />Natural ^Homicide
<br />^ NOl pregnant within past year ^ YES ~ NO
<br /> ^ Pag6angef
<br />^ Pregnant at time of death ^ Accldem^ pending Investigation .~
<br /> ^Pedestrlan 21d.WEREAUTOPSYFINDINOSAVAILASLETO
<br /> ^ Nat pregnant, but pregnant within 42 days of death ^ Suicide ^ COUId not be determined
<br />^Other (SpBClfy)
<br />
<br />- COMPLETE CAUSE OF DFATH7
<br />~O Not pregnant, nut pregnant 43 days to 1 year before death
<br /> ^ Unknown II pregnant within the past year ^ YES ^,NO
<br />*' 22a. DATE DF INJURY (Mb., Day, Yr.) 224. TIME OF INJURY 22e. PLACE OFINJURY-At home, farm, street, laetory, Office building, construction Bite, etc. (Speeily)
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<br />22d.INJl1RYATWORK2 22e.0E5CR16~HOWINJURYOCCUAR(:p. ~-~ '-':. - --~- - . - ._.. .., ..
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<br />~ ^ YE5 ^ NO
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<br />-:.~~ STATE ZIP CODE
<br />22f. LOCATION DFINJURY-STREET&NUMBER, APT.NO. CfTYfI'OWN
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<br />-~. 23a.DATEOFDEATH (Mo.,gay,Yr.) _~ 24a.DATE5IGNED (MO.,oay,Yr.) 24b.TIMEOFDEATH
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<br />s N yg Yr. 24d.TIMEPRONOUNCEDDEAD
<br />~ } 234, DATE SIGNED (Mo., Day, Yn) 23c.71ME OF DEATH m G 24c. PRONOUNCED DEAD (Mb., Day, )
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<br />2009 ~1: 00 A. m
<br />28
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<br />August
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<br />24e. On ins oasts Of examination andlOr inveatigatlOn, In my opinion death Occurred et
<br />23d. TO the bast Of my knowledge, death ooburred at the time, date and place ~+ uQl ~
<br />~ the time, date and place and due tb the cause(s) staled. (Signature and Title)
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<br />~ and due to the Cause(s) stated. (Signa
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<br /> 25. DIDTOBACCO USE CONTRIBUTETO THE DE 28d. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTEb7
<br /> Q YES Nq ^ PROBABLY ^ UNKNOWN [] YES NO NOt Applicable If 28a is NO Q YES ^ NO I
<br /> 27. NAME, TITLE AND ADDRESS DF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN DR CDUN7Y ATTORNEY) (Type Or Print)
<br />68803
<br />'
<br /> Tsland, *'E
<br />P1.D., Grand Tsland Veterans Icane, Gram
<br />,7ennifer Kin
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<br />28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mv., Day, Yr.)
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<br />HHS-61 11/03 (55081)
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