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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF'HEALTM ~4NA~UMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE N~'BRA~`C~55~°P,,Q~2fUT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY f(7 ~r'IT~~-kE~~~Fjjl~~~
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<br />.DATE pF ISSUANCE '
<br />s$T~}'I1~EY S:, COOPER
<br />aPR 0 6 2089 `~ ~ Q 9 ~ 9 3 41 ~,a.xsrA~~Ar,~:~~r~rR~-a', '
<br />' ~~PARTJr~IVttDFl~~li ANbW.
<br />LINCOLN, NEBRASKA 'Hf~q:~N ~E''RV~CES ~ .-
<br />STATE OFNEBRASKA- CF=PARTMENT OF HEALTH ANC HUMAN SERVICES FINANCE` ~1~VfJ"SUI?PAR •, ~""~
<br />CERTIFICATE OF DEATH
<br /> t. DECEDENT'S•NAME (First, Middle, Lest, Suffix) 2. SEX 3.DATt:'OFOEATH(Mb„Oay,Yr.)
<br /> Lenora Arden. Moue Female March 28, 2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Leer Birthday 5b. UNDER t YEAR 5c. UNDER t pAY 8. PATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HDUR$ MINS.
<br /> Laramie, Wyoming 68 November 27. 1940
<br /> 7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br /> 507-44-4888 J{Qgj=ItAL: ^ Inpatient 9IdEB: ]~INuraingHomalLTC ^HoepiceFacility
<br /> Bb. FACILITY•NAME (If not Institution, glue arrest and number)
<br />^ ERlOutpallent ^ Decedent'aHome
<br /> Good Samaritan Center
<br /> ^ ~,, ^Diner (specity)
<br /> 8c. CITY OR TOWN OF pEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br /> __ Wood River 6$8$3 Hall
<br /> 9a. RESIDENCE-STATE 8b.000NTY 9c. CITY OR TOWN
<br /> Nahraska Hall Wood River
<br />" Bd. STREETANDNUMBER Be. APT. NO 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />~K 9026 West Hailing Road 68883 ^ vas ~ ND
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<br />11)a. MARITAL STATUS ATTIME OF DEATHMarried ^ Never Married tOb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br /> ^ Married, but separated ^ Widowed ^ Divorced ^ Unknown Dale MOUl
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<br />`~ ti. FATHER'S-NAME Firer, Meddle, Last, Sufllx 72. MOTHER
<br />( ) 'S-NAME (First, Middle, Maiden Surname)
<br />~a: Carl W. Taylor Sert3.na K. Merrill
<br /> 13. EVER IN U.S. ARMED FORCE57 Glve dates of service if yes. t4a. INFORMANT•NAME 14b. RELATIONSHIP TO pECEpENT
<br />' " (Yea, no, or unk) No Dale Moul Husband
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<br />~~ . 15. METHOD OF DISPOSITION Ise. E L ER•SIG ATUR 16b. LICENSE N0._ 78c. DATE (Mo„ Dey, Yr. )
<br />, ^Burial ^wnation O i'~ELrCh 3-1 ,. Z'009
<br /> ~iCremation ^ Entombment i8d. CEMETERY, CREMA70 OR OTHER LgCATIpN CITY /TOWN STATE
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<br /> ^ Removal L7 Other (Specify)
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<br />Westlawrn Memorial Park Crematory, Grand Island, NE
<br />_ 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Stree4 City orTown, State) -. 17b. Zlp Code
<br />~~-"~_ Apfel Funeral Home, 1123 West Second, Grand Island, NE 68801
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<br />18. PART I. Enter the g,qQ,~ v nt ••diseases, injuries, or complicationa••thal directly caused the death. DD NOT enter terminal events such as cardlev arrest, APPROXIMATE INTERVAL
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<br />respiratory erred, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter Only One Cause On a Ilse. Add edtlitionel linen if necessary. l
<br />IMMEDIATE CAUSE: l ons
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<br />wy dleeaeeorcondidonreeulting pUETO,ORASACONSEgUENGEgF:
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<br /> any,leadingtotheceuaelieted OUETO,ORASA4CONSEgUENCEOF: I onset todeatn
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<br />DUE TD, OR AS A CON5EgUENCE OF:
<br />l onset tc death
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<br />~.; ~~:` ; 78. PART IL OTHER SIGNIFICANT CONOITIONS•Cvntlitivns contributing to the death but hat reaulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
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<br />( G'~'m ^ YES NO
<br />_ 20. IF FEMALE: 21a.MANNER OF DEATH ~~ 21b. IF TRANSPORTATION INJURY 21 c. WAS AN AUTOPSY PERFORMEp?
<br /> ~NOt pregnam within pest year ~'Neturel ^ Homicide ^ DrlverlOperator
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<br />_ ^ Pregnant at time of death
<br />^ Accident^ Pending Inveatlgatlon O Passenger ^ VES (~NO
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<br />^ Nnt pregnant, but pregnant within 42 days of death
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<br />^ Suicide ^ Could not be determined
<br />^ Pedestrian _.~ m
<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE TD
<br /> ^ Nat re nant, but re pant 43 da a to 1 ear before death
<br />A 9 A 9 Y Y ^ Other (Specify)
<br />COMPLETE CAUSE OF pFJtTH7
<br /> ^ Uhknvwn if pregnant within the past year ~ ^ YES ^ ND
<br />~° 22a. DATE OF INJURY (Mo., Day, VL) 22b. TIME DF INJURY 22C. PLACE OF INJURY-At home, farm, street, factory, office building, CpnatrpCtlOn alts, eta (SABCIfy)
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<br />.~'=~. `. 22d.INJURYATWDRK? 22e.DESCRIBBHOWINJURYOCCURRED
<br /> ^ YES ^ NO
<br /> 22i. LOCATION OF INJURY -STREET 8 NUMBER, APT. N0. CffV/TOWN STATE ZIP CODE
<br />- 23a. DATE OF DEATH (Mc., Dey, Yr.) _ ~ 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIME OF DEATH
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<br />23b. DATE SIGNEp (Mo., Dey, Yr.) 23c.TIME OF EA7H ~ ~ _ ~ 24c. PRONOUNCED DEAD (Mo., Day,Yr.) . 24d. TIME PRONOUNCED DEAD
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<br />_ ~ :0 23d. To the beet vl my knowledge, death occurred at the lime, date and plac0 W ~ 24e. On the basis of examination and/or Inveatlgallvn, in my opinion death occurred at
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<br />ue to the cause(s) stated. (
<br />ignature and Title) • o p G the time, date and place ana due to the cause(s) stated. (Signature and Title)
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<br />_ 25.DIDTOBACCOUSECONTRIBUTETOTHEOEATH? 26a.HASORGANORTISSUEDONATIDNeEENCgNSIPEREp7 26b.WASCONSENTGRANTED?
<br /> ^ YES_-~NO ^ PROBABLY ^ UNKNOWN
<br />- .. __~ ^ YES D
<br />_T...__ Not Applicable i1.2se is NO ^ YES ~ NO
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<br />'- 27.NAME,TITLEANDApDRESSOFCERTIFIER (PHYSICIAN,CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br /> Anne Morse M.D. 729 N. Custer Ave., Grand Island, NE. 68803
<br /> 288. REGISTRAR'S SIGNATURE 28b. DATE FILED 8Y R_EG_ ISTRAR (MO., Day
<br />Yr.)
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