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STATE OF NEBRASKA
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<br />WHEN TMIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ~Vd~''Y~~I~I~t,I~,~FjRVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA''b 1=W1; (~~' HF~ALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR. VITA ~ C
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<br />~~.
<br />DATE OF ISSUANCE '°
<br />.~.' ~',
<br />09/30/2009 2 010 01 ~ 4 ~ ~~~sT~+~tT ~ I rRAR ~ ~,~ ~'
<br />pE~1R~M~CV~.QF'M~~ANla't": ,.„
<br />LINCOLN, NEBRASKA F1U11'>"~1/tP~~C:~T~ ., r ~•~
<br />Amended STATE OF NEBRASKA-DEPARTMEN70F HEALTH AND HUMAN SERVI(~5~~.~ a~~';~YC "t .~,~'~~~~~ 0,1970
<br />CERTIFICATE OF DEATH P 1 , '~T ;' • • • , ,. ;, ~,~~ .,.
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX ~ w 11E F D A~ o., Day, Yr.)
<br /> Ma Lou Mueller Female yAugtt~h.'#0, 2009,
<br /> 4. CITY AND S7A7E OR TERRITORY, pR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY. 8. DATE OF BIRTH (Moe Day, Yr.)
<br /> IY~sd MOS. DAYS HOUR$ MINE. -
<br /> Ocpntp, Nebraska 76 October 27, 1932
<br /> 7. SOCIAL SECURITY NUMBER Sa. PLACE OF DEATH
<br /> 505-36-9516 ~$Pljq.4 ©Inpatient OTHER ^ Nursing Hpma/LTC ^ Hasplce Facility
<br /> 86. FAGILITY•NAME (If not Institution, glue street and number) ®ERlOutpatient ^ Decedent's Hame
<br />K
<br />~
<br />V Saint Francis Medical Center ^ Doa ^ Other (Specify)
<br />~ 8c. CITY OR TOWN pF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />S Grand Island 68803 Hall
<br />J ga. RE81pENCE-STATE 8b. COUNTY 9c. CITY OR TOWN
<br /> Nebraska Hall Grand Island
<br />9 9d. STREET AND NUMBER 9e. APT. NO. 8f. ZIP CODE 9g. IN81DE CITY LIMITS
<br />~ 1923 West 10th 68803 ®YES ©No
<br />
<br /> 10a. MARITAL STATUS AT TIME OF DEATH ®Marrled ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, glue maiden name
<br />!E
<br />d ^Marrled, but separated ^ Widowed ^ Divorced ^ Unknown Edward Mueller
<br />~ 17. FATHER'S•NAME (First, Mlddl6, Last, Suffix) 12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br /> August Henry Meyer Evelyn Iris McNutty
<br />°'
<br />E 13. EVER IN u.5. ARMED FORCES? Give dates of service IT Yas. 14a. INFORMANT-NAME 10.b. RELATIONBHIP TO DECEDENT
<br />$ (Yea, No, or unk.) No Edward Mueller Husband
<br /> 15. METHOD OF DISP03mON 18a. EMBALMER-8IGNATURE 18b. LICENSE NO. 18c. PATE (Mo., Day, Yr.)
<br />D
<br />~ ®Burlal ^ Donation Chris McCoy 1191 September 2, 2009
<br /> ^ Cremation [] Entombment BTATE
<br /> 15d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN
<br /> ^ Removal ^ Other (Specify)
<br /> Grand Island City Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zlp Code
<br /> Livingston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 68803
<br /> AU D AT ee Instructions an exam es
<br /> 1t1. PART I. Enter the gtlaln of aventa• •dlooaooa, InJudeB, or compllWtlona-that dlrocty caawd the duth. DO NOT Dolor tarminel OvAnta such AA cardiac arrost, :APPROXIMATE INTERVAL
<br /> respiratory AYrdst, Or ventricular gbrllldtlon wltnout showing the otlology. DO NOT A88REVIATE. Enter duly one cauw On d IInA. Add additional Ilnaa IT nowaaary.
<br /> IMMEDIATE CAUSE: ~ onset to death
<br /> IMMEDIATE CAUSE (Final al Senescence E Gradual
<br />.. disease or condition reapltlnq
<br /> In death) pUE Tp, OR AS A CONSEQUENCE OF: 7 onset to death
<br /> SequantlAlly IIK conditions, If b) Renal Failure :Gradual
<br /> any, IoAdlnq to ene cause listed
<br /> on Ilns a. DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYIND CAUSE C)
<br /> Idlasap or InJury that Inltlatad
<br /> the events rosuklnq In death) pUE 70, OR AS A CONSEQUENCE OF: onset to death
<br /> LA8T d)
<br /> 18. PART II. gTHER SIGNIFIGANT CONDITIONS-Condltlons contributing to the death but not rbaulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> Deep Veln Thrombosis, CellUlitis, Anemia, Hypertension OR CORONER CONTACTED?
<br /> ^YES ®NO
<br />~
<br />4J
<br />LL 20. IF FEMALE: 27a. MANNER OF DEATH 21 b. IF TRANSPORTATIpN INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br /> ^ Not prognant wlthln past year ®NAturAl ^ Homicide ^ Drlwr/Operator ^YES ®NO
<br />U ©Pregnant at time of death ^ Accldanl ^ Pondlnq Inwatlgatlnn ^ Paswngor
<br />a ^ Not pregnant, but prognant wlthln 42 days of death gviciaa Could not be determined
<br />~ ~ ^ Podastdan 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />A
<br />SE OF DEATH?
<br /> ^ Not prognant, but prognant 49 days to 1 year before Aedln ^ Other (Specify) TO COMPLETE C
<br />U
<br /> ^ Unknown If prognant wthln the peat year ^YES ^ NO
<br />a
<br />E 22a. DATE OF INJURY (MO., Day, Yr.) 226. TIME pF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (SpacHy)
<br />
<br />Sr 22d. INJURY AT WORK? 226. DESCRI9E HpW INJURY OCGURREp
<br />0
<br />~'
<br />^YES ^ NO
<br /> 22f. LOCATION OF INJURY -STREET 8 NUMBER, APT.Np. CITY/TOWN 8TATE ZIP CODE
<br /> 23a, DATE OF DEATH (MO., Day, Yr.) 20.a. DATE SIGNED (Mo., Day, Yr.) 2db. TIME OF DEATH
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<br /> ~.W. _ - _ _ _..: A -'S tember 8: 2009 _ _- 07:26
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<br /> lac. PRONOUNCEp DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />236. DATE SIGNED (Mo., Day, Yr.) 23ti. TIME pF DEATH ~ k
<br /> r
<br />Y
<br />~" = E a ` ~ AU ust 30, 2009 07:25 AM
<br /> p 29d. Td the bowl of my kndwledgo, death Occurred al the time, date and place 8 240. Dn the basis of examinadon andlor Inwstigatlon, In my dplnlon death occurred at
<br />$ Z
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<br /> p the limo, date Antl place and due to the cauaata) stated. (Signature and Tnle)
<br />and duo to lire cduwlsl atetaA. ISipnaturo and Tkle)
<br />tt
<br />~ ~ ~ ~ O
<br /> orney
<br />a Aaron Kunz, Hall Deputy County A
<br /> 25. DID T08ACC0 U8E CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 286. WAS CONSENT GRANTED?
<br /> ^ YES ^ NO ^ PROBABLY ® UNKNOWN ®YES ^ NO Not Applicable K 28a Is Np ©YES ®NO
<br /> I ype Dr r n
<br /> Aaron Kunz, Hall Deputy County Attorney, 231 S. Lpcust, I'.O. Box 367, Grand Island, Nebraska, 68802
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED aY REGISTRAR (Mo., Day, Yr.)
<br /> September 10, 2009
<br />Amended
<br />8/30/2009 Items B, 18d
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