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<br /> STATE OF NEBRASKA
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AN(7 MUMgN,SERVICES, IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL PCIco, AD'S
<br /> DATE OF ISSUANCE
<br /> STANLEY S..C ORER
<br /> rr,
<br /> AU G 0 7 2009 ASSLSTA TT 1~?r T REGI$7R4{24I
<br /> DEPARTM~N~' trlE,4LT~NQ
<br /> 201001083
<br /> LINCOLN, NEBRASKA HUMAN.SERVICFS ,
<br /> STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPO
<br /> CERTIFICATE OF DEATH 4J7~ ~ .2
<br /> 1. DECEDENT'S•NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo.,Day. Yr.)
<br /> .john Neil Hu hes Male 7/31/2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Lasl Birthday 5b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DpY5 HtlURS MINS. -
<br /> Howard County, Nebraska 84 8/18/1924
<br /> 7, SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 506--20-3020 - N &_LTAL: Q Inpatient QTypg; M NursingHome/LTC ❑FlospiceFacility
<br /> Bb. FACILITY-NAME (It not Institution, give street and number)
<br /> ❑ ER/Outpatient ❑ Decedent's Home
<br /> Tiffany Square Care Center ❑ D04 ❑other(Specify)
<br /> 7 8c. CITY OR TOWN OF DEATH (Include Zip Code) - - - -
<br /> Old. COUNTY OFDEATH
<br /> Grand Island Hall
<br /> 9e. RESIDENCB-STATE 91. COUNTY 9c.CITYORTOWN
<br /> Nebraska Hall Grand Island
<br /> e,
<br /> 9d. STREET AND NUMBER 9e. APT. NO 91. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 3020 West North Front Street 68803 n YES ❑-NO
<br /> 10a. MARITAL STATUS AT TIME OF DEATH EAMarried ❑ Never Married lob. NAME OF SPOUSE (First, Middle, Last, Suffix) II wife, give maiden name.
<br /> t V ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br /> ~ Y Emma Fellows Trull
<br /> 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12, MOTHER'S-NAME (First, Middle, Maiden Surname)
<br /> Tames
<br /> U'~-- Z~ona MurieL$d
<br /> N' 13. EVER IN U,S. ARMED FORCES? Giv dales of service If yes. taa.INFORMANT-NAME 14b. RELATIONSHIP To DECEDCN7 -
<br /> (Yes, no, or unk.) yes 11/"19%1948 1/10/
<br /> VImma 0 wife
<br /> .
<br /> .
<br /> 15. METHOD OF DISPOSITION 18a. EMBALMER-SIGNATURE tea. LICENSE NO. 18C. PATE (Mo., Day, Yr. )
<br /> b ❑Burial ❑Donation not embalmed
<br /> 8/1/20 9
<br /> = y Cremation ❑ Entombment I8d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br /> ~!v ❑ Removal Q Other (Speclly)
<br /> ;r Westlawn Memorial Park Crematory Grand Island NE
<br /> 1, ? 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Slate) 171il. Zip Code
<br /> a Apfel Funeral Home 1123 West 2nd Street Grand Island, Nebraska 68801
<br /> 18. PART I. Enter the Chitin of events-diseases, Injuries, or compllcalions"•thai directly caused the death. 00 NOT enter terminal events such as oardiac arrest, APPROXIMATE INTERVAL
<br /> iF. respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. ,
<br /> IMMEDIATE CAUSE: onset to death
<br /> I
<br /> IMMEDIATE CAUSE (Fine l (a) ~ (A'L Ott
<br /> _ dleeeeaorcondllivnreaultlnp DUE TO, ORA9AC SEOUENCE0F:
<br /> In death) onset to death
<br /> ~ I
<br /> Sequentially list conditions, if (bl ` , I
<br /> any, leading to the cause listed DUE TO,ORA A CONSEQUENCE OF:
<br /> on line a. I onset to d de th
<br /> e
<br /> .~•.~1 Enter the UNDERLYING CAUSE
<br /> .t (disease or Injury that initiated (c)
<br /> the wants resulting In death) - 1 _
<br /> <-off LAST DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br /> (d) I
<br /> 18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditlons contributing to the death but not resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> Q YES ❑ NO
<br /> T20.IFF MALE: 21a.M~A NEROFDEATH 21b. IF TRANSPORTATION INJURY 21c.WASANAUTOPSYPERFORMED?
<br /> L
<br /> Q Not pregnant within past year W Natural ❑ Homicide Q Driverloperator
<br /> W'i Q Pregnant at time of death El Q Passenger ❑ YES NO
<br /> U ACCidenl❑ Pending Investigation
<br /> ~s ❑ Not pregnant, but pregnant within 42 days of death C3 El Pedestrian
<br /> Suicide Q Gould not be determined 21 d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br /> t Q Not']Iregnanl, but pregnant 43 days to 1 year before death Other (Specify)
<br /> COMPLETE CAUSE OFDEATH?
<br /> ❑ Unknown if pregnant wllhln the peal year ❑ YES ON 0
<br /> C4^; 22a. DATE OF INJURY (Mo., bay, Yr.) 221. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, canstructlon site, etc. (Specify)
<br /> m
<br /> 22d.INJURYATWORK7 22e. DESCRIBE HOW INJURY OCCURRED
<br /> C] YES NO
<br /> 22f. LOCATION OF INJURY • STREET & NUMBER, APT. No. CITYR'OWN STATE ZIPCODE
<br /> 23a, DATE OF DEATH (Mo., Day. Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> t}A~ 23b. DATE SIGNED(Mo., Day, Y[,) 23C, TIME OF DEATH 24C. PRONOUNCED DEAD(Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> 110 171
<br /> g 23d. To the best of my knowledge, death occurred at the time, date nd place 24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br /> o us to use(s) stated, (Signature and Title) T the time, dale and place and due to the cause(s) stated. (Signature and Title) T
<br /> to- 8
<br /> 0 C.)
<br /> 25. DIDTOBAC USE CONTRIBUTE TO THE DEATH? 28a. HAS ORDAN OR TISSUE, DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br /> ❑ YES 060 ❑ PROBABLY UNKNOWN_ Q YES LM O _ Not Applicable if 26a is NO ❑ YES 9T NO
<br /> 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) "
<br /> Ryan D. Crouch 800 Alpha Street Grand Island, Nebraska 68803
<br /> i 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> AUG 5 2009
<br /> HHS-61 11/03 (55061)
<br />
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