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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HE,4~,Tki~YYl~. D M~j~B:E VICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRf~'SI~E~~1~~1~1ENfi.0~~ l-1EALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH TS THE LEGAL DEPOSITORY FORMVIc~~TR~C,S~ +
<br />DATE OF ISSUANCE ~" a ~~
<br />J
<br />10/30/2009 2 0 0 9 U 9 316 S fANL~EY ~'~P,~R ~ ~~ a
<br />AfiS~ISTANu~~="5.~~TE ~C,.ir~S7"RA~ ~f
<br />D~PA}~TM~IVT O'F HEA"LT~/~`~I,PL? r~.,
<br />LINCOLN, NEBRASKA NlfNt~AN•SCr ICES:', '
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERSI~E$'~ti ~ '~.1" a - ~h_ ~'~ ~ ~' - re tt ~, ` 09 02440
<br />CERTIFICATE OF DEATH ,'1 ! ~ , ; !
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX ` '~, 3,. DpTG OF pEATH (Mo., Day, Yr.)
<br /> Keith Maurice Skeels Male October 20, 2009
<br /> 4. CITY ANp STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE -Last 8lrthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. PAYS HOURS MINS.
<br /> Grand Island, Nebraska 87 Janus 31, 1922
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE pF DEATH
<br /> 506-18-7506 HOSPITAL ®Inpatient OTHER ^ Nursing Hpme/LTC ^ Hospice Facility
<br /> Bb. FAGILITY-NAME (M not Institution, glue street and number) ^ ER/Outpatlent ^ DecederH's Nome
<br />K
<br />U
<br />Saint Francis Medical Center
<br />^ DoA ^ Other (Specfy)
<br />~ 8c. CITY OR TOWN OF DEATH (Include Zip Code) Bd. COUNTY OF DEATH
<br />`o Grand Island 68$D3 Hall
<br />J 9a. RESIDENCE•STATE gb. COUNTY 9c. CITY OR TOWN
<br /> Nebraska Hall Grand Island
<br />LL gd. STREET AND NUMBER e. APT. NO. 8f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />T 2524 W, Anna 5t 68803 ®YES ^ No
<br />a 10a. MARITAL STATUS AT TIME OF DEATH ®Married ^ Never Married 106. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maldsn name
<br /> ^ Marrlad, but Separated ^ Widowed ^ pivorced ^ Unknown Florene Stroh
<br /> 11, FATWER'S-NAME (First, Middle, Last, Suttlx) 12. MpTHER'S-NAME (First, Middle, Malden Surname)
<br />~ Maurice L Skeels Goldie Moses
<br />a 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. 74a. INFpRMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />~ (Yes, No, or unk.) Yes 12/24/1942-11/06/1945 Florene Skeels Wife
<br />m
<br />A 15. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURF 18b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />N ®Burlal ^ Donation
<br />Patricia R. Curran
<br />1092
<br />October 23, 2009
<br /> ^ Cremation ^ Entombment
<br /> 18d. CEMETERY, CREMATORY OR pTHER LOCATION CITY !TOWN STATE
<br /> ^ Removal ^ ether (Specify)
<br /> Grand Island City C®metery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, State) 17b. Zlp Gode
<br /> Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 68801
<br /> AU E F D TH ee nstructions and exam es
<br /> 18. PART I. Enter the chal events-•diseaws, InJurias, or compllcatlona-that directly auaeq the death. DO NOT enter terminal avanta such as cardiac arrest, APPROXIMATE INTERVAL
<br /> reaplratory arrant, dr ventricular flbrlllatidn witheut showing the etiology. DO NpT ABBREVIgrE. Enter only one cause on a Ilne. Add addltldnal Ilnea If neteawry.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final a) Sepsis ;Days
<br /> disease or nnndition resufling
<br /> in death) DUE TO, OR AS A CONSEQUENCE OF; onset to death
<br /> Ssquentlally Ilst condl[lana, If b) Pneumonia i Days
<br /> any, leading to the Hues Ilated
<br /> on Ilna a.
<br />pUE TO, OR AS A CONSEQUENCE OF; onset to death
<br /> Enter the UNDERLYING CAUSE C)
<br /> Idlaeaae or Injury that iNtiated
<br /> the events resulting in death) DuE Tp, OR A3 A GONSEQU&NCE OF: onset to death
<br /> ~Asr d)
<br /> 18. PART I1. pTHER SIGNIFICANT CONDITIONS-Conditions contrl6uting to the death but not resulting In the underlying Cause given In PART I. 19, WAS MEDICAL EXAMINER
<br /> pementia, OR CORONER CONTACTED?
<br />~ ^YES ®NO
<br />w 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21 c. WAS AN AUTOPSY PERFORMED?
<br /> ^ Not pregnant within past year ®Natural ©Homlclde ~ prlvedpparator
<br />
<br />~
<br />^ Pregnant at Uma dt death
<br />^ Accident ^ Psndlnp Inveatigatlon
<br />^ Paaaenger ^ yes ® NO
<br />
<br />~` ^ Not pregnant, but pregnant within 42 days of death
<br />©$ukida ^ Could net ba determined ^ Padeitrlan 27 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />
<br />a
<br />^ Not pregnant, but prapnant 43 days td 1 year before death
<br />^ Other (Specify) TO COMPLETE CAUSE OF DEATH?
<br />+~
<br />d ^ UnkndWn if pregnant within the peat year ^YES ^ NO
<br />~-
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 226. TIME pF INJURY 22c. PLACE OF INJURY•At home, farm, street, facto
<br />ry, office building, construction alts, etc. (Specify)
<br />
<br />,~' 22d. INJURY AT WORK? 2Ze. pESCRIBE HOW INJURY OCCURRED
<br />O
<br />F"
<br />^YES ^ NO
<br /> 22f. LOCATION OF INJURY • STREET & NUMBER, APT.Np. CITYITOWN STATE ZIP COPE
<br /> 23a. DATE OF DEATH (Mv., Day, Yr.) _ _ - 24a. DATE SIGNEp (MO„ Day, Yr.) Z46, 711JAE OF DEATH
<br />- _
<br />~ ~-~ -October 20, 2009 ~
<br /> ~ ~ 23b. DATE SIGNED (Mo., Day, Yr.)
<br />~ 23c. TIME OF DEATH ~ ~ ~ 24c. PRONOUNCEp DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> ~
<br />Z October 27, 2009 01:00 AM e ~ e ~
<br /> ~ Sd. To [ha beat pf my knpwlede9, death oCCUrreA at the tlrrw, dots and place
<br />~
<br />d d ~ ~
<br />$ ~ 24e. On the basis of axaminatlon and/or Invaa[Igatlon, In my opinion death occurred at
<br /> an
<br />ue to the Cauaelt) stated. (Signature and Title) p the time, date and plats and tlua to the teasels) atatad. (Signature and Title)
<br /> ~ ~ Jay C. Anderson, MD ~
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS pRGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br /> ^ YES ®NO ^ PROBABLY ^ UNKNOWN ^YES ®Np Not Applicable If 26a Is Np ^YES ^ NO
<br /> .NAM , TI L A RN Y) (Type or rlnt
<br /> Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED 8Y REGISTRAR (Mo., Day, Yr.)
<br /> October 28, 2009
<br />~x~fL~~~ ~r~ ~~
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