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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA D~~~,4~BT.ML4(V.T OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITA. L"R~~'Q lr7S, ~ ~ ,
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<br />DATE OF ISSUANCE ~~.~~ , r ~~ ,
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<br />2 o i o 0 0 3 5 3 .STA1V(~k'?'.5. ~oOPER
<br />12/03/2009 AS.~I~ANT STA'l`E•,RLtGT,~s7"RA~f~ s~,
<br />4~PA`RTMEN~'0!~w7'-lF,+~L7'1''A~1/D'' `.
<br />LINCOLN, NEBRASKA HUMAN ~$'ER^V~OES .~ :. a .r
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVJCE~, ~ , ~ -', Qg UZT46
<br />CERTIFICATE OF DEATH ~ ~'~ ;: ;-;; , :~~ :,w'~''~'
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX `; ~• S, PAT OF pFRTW 4MO., pay, Yr,)
<br /> Donald David Lace Male a . "'N'gv~r>;Ib'e~ 1.7°;'2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE -Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY ~~.. ~ ¢: DATEOF,BYRTH (Mo., Day, Yr.)
<br /> (Yrs.l MOS. DAYS HOURS MINE.
<br /> Rural Shelton, Nebraska 84 March 31, 1925
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 507-38-5164 1jS2&P1TAL ®Inpatlent OTHER ^ Nursing Home/LTC ^ Hospice Facility
<br /> Bb. FACILITY-NAME (If not Institution, glue street and number) ^ ER/Outpatlent ^ Decedent's Home
<br />D:
<br /> Phelps Memorial Health Center ©DOA ^ Other (Specify)
<br />
<br />C 8c. CITY OR TOWN OF DEATH (Include Zlp Codas 8d. COUNTY DF DEATH
<br />o Holdrege 68949 Phelps
<br /> 9a. RESIpENCESTATE 9b, COUNTY 9c. CITY OR TOWN
<br />z Nebraska Phelps Holdrege
<br />LL 9d. STREET AND NUMBER e. APT. NO. 9f. ZIP CODE 9g. INSIDE GITY LIMITS
<br />T 1320 11th Avenue 68949 ®Yes ^ No
<br />'a
<br />t'~ 10a. MARITAL STATUS AT TIME OF DEATH ^ Married ®Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) K wife, glue maiden name
<br />m
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<br />^ Manled
<br />but separated ^ Widowed ^ pivorcad ^ Unknown
<br /> ,
<br /> ' '
<br />~ 11. FATHER
<br />S•NAME (First, Middle, Last, Suffix) 12. MOTHER
<br />S-NAME (First, Middle, Maiden Surnema-
<br />~ Walter D Lacey Hattie Williams
<br />~'
<br />E 13. EVER IN U.S. ARMED FORCES9 Give dates of service if Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP Tp DECEDENT
<br />$ (Yea, No, or unk.- No Nanc Hansen Niece
<br /> 15, METHOp OF DISPOSITION 18a. EMBALMER-SIGNATURE 18b. LICENSE NO. i8c. DATE (MO., Day, Yr.)
<br />~
<br />~ ®8urlal ^ Donation
<br />Eric J
<br />Van Horn
<br />1408
<br />November 21
<br />2009
<br /> . ,
<br /> ^ Crernatlon ^ Entombment
<br />
<br />^ Removal ©Other (Specify) 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> Shelton Cemetery Shelton Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty ar Town, State) 17b. Zip Cada
<br /> O'Brien-5traatmann Funeral Home 4115 Avenue N PO Box 2344 Kearne Nebraska 68847
<br /> DEATH ee instructions and exam es
<br /> 79. PART I. Enter the chain of events- •d4esses, IaJurles, tlr complications-that dlrsctly cauasd the death. DO NOT enter terminal evenro ouch as cardiac amat, ; APPROXIMATE INTERVAL
<br /> raaplratdry arrest, or ventACUlar }Ibrlllatlon without ahowlnp the etlolopy. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add addltldnal Ilnea If nacaaaary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final a) Congestive Heart Failure ;Days
<br /> dlssaw or contlklon rowlthtp _ ~ .._. _
<br /> In death) DUE 70, OR AS A CONSEQUENCE OF: onset to death
<br /> Saquantlally Ilst cpndltldna, If b) Cardiomyopathy :Days
<br /> any, leading td the 4auad listed
<br /> on Iins a.
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Entartha UNDERLYING CAUSE Gl Acute Myocardial Infarction ;Days
<br /> (dlsddae w InJUry that Initldtsd
<br /> the evante reaulUne In death) pUE TO, OR A5 A CONSEQUENCE OF: onset to death
<br /> L"ST d) Coronary Artery Disease ;Years
<br /> 18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> Parkinsons Disease, Dementia OR CORONER CONTACTED?
<br />ar ®YES ^ NO
<br />W 20. IF FEMALE: 21 a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />~ ©Not PreCnant wAhin past year ®Naturol ^ Homicide ^ Drivsrlpperator
<br /> ^ YES ® NQ
<br />W ^ PrepnAM at time of death ^ ^
<br />Accident Pentllnp Invsatlpatlon ^ PdaaBnpdr
<br />t
<br />.1
<br />a ^ Not prspnant, but propnant wlthln 4Z days of death
<br />^ Sulclda ^ PidYIA not ba damrminad ^ Petlsstrian 21 d. WERE AUTOPSY FINpINGS AVAILABLE
<br />
<br />~
<br />^ Not pregnant, but prspnant 43 daya to 7 year bsforv death
<br />^ Other (SpsciTy) TO GOMPLETE CAUSE OF pEATHY
<br />~ ^ Unknown If propnant wlthln the past year ^YES ^ NO
<br />
<br />E 22a. PATE pF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />
<br /> 22d. INJURY AT WORKS 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
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<br />^YES ©NO
<br /> 22f. LOCA710N OF INJURY • STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br /> 23a. DATE OF bEpTH (Mo., Day, Yr.) 24a. PATE SIGNED (Mo., Day, Yr.) .. 24b. 71ME OF pEATH
<br />~ ~
<br /> ~ W November 17, 2009 ~
<br /> r 23b. DATE SIGNED (MO., Day, Yr.) 23c. TIME OF DEATH ~ ~ ~ r 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> ~ December 1, 2009 10:48 PM
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<br />aaatn occurred at the time
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<br />nature antl Titlel w Y4a. On the balls of axaminatlon andlar Invas[Ipatlon, In my opinion death occurred al
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<br />o S the time, data and plats and due to the cauas(s) stated. (Signaturo and Tkle)
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<br /> ~ Jeffrey Berney, MD g
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<br /> 25. DID TOBACCO USE GONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br /> ^ YES ®NO ^ PROBABLY ^ UNKNOWN ^YES ®NO Not Applicable If 28a Is NO ^YES ^ NO
<br /> 2 . NAM 1 N R (P A - ( ype or riot)
<br /> Jeffrey Berney, MD, 516 West 14th Avenue, Holdrege, Nebraska, 68949
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> December 1, 2009
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