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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND MUMAN SL~RVIGES
<br />SYSTEM, lT CERTIFIES THE BELOW TO BE A TRUE DOPY OF THE ORIGINAL R' CIQ,A FILE WITM
<br />THE NEBRASKA HEALTM AND HUMAN SERVICES SYSTEM, VITAL STATISTId`.~~Cr"~~`I~(j~I~J~ IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. +~* ,,~ • ~~~ddd f~ v' ~ ,
<br />
<br />DATE OF ISSUANCE
<br />~IA~ ~ '~ ~~~.
<br />LINCOLN, NEBRASKA
<br />2 010 0 ~~-5 5 A~IST . s T ~ ~ ;~
<br />i~a~~ ai ~ ~I~es..;
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<br />,'' ts~~,33 • I = ~ ~ 1
<br />STATE OFNEBRASKA-pEPARTMENT OF HEALTH AND HUMAN SERVICES FINY4))ICb~Nti • Q" ••
<br />CERTIFICATE OF DEATH `"1, ~•° ~
<br />1. DECEDENTS NAME (First, Mlddle, Last, Suffix) 2. SEX ,t ~ ~OFDEgTH,(Mawbay,Yr.)
<br />,_ Virginia „__Lrauise Lewis Female3 ~°; .~~~h 7, ..2'008
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY DF BIRTH 5a. AGE•Last Birthday 56. UNDER 1 YEAR 5c. UNDER 1 DqY B.,DATE OF BIRTH (Mo., Dey, Yn)
<br />Lincoln, Nebraska (Yrs.) $6 MOS. DAYS HOURS MINE. L)illguEa 15, 1921
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />506-16-3926 HD.SPJ7BL; ~Ilnpetlent 1pISEB ^NursingHOme/LTC ^HOSpIceFecility
<br />Bb. FACILITKNAME (11 not Instltutlon, glue street end number)
<br />^ ERlOutpatlent ^ Decadent'sHome
<br />St. Francis Medical Center
<br />^ o~ n Other(3peclfy)
<br />Bc. CITY OR TOWN OF pEATH (Include Zlp Coda) Bd. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />ga. RESIDENCE•STATE 9b. COUNTY Sc. CITY DR TOWN
<br />Nebraska Hall Grand Island
<br />gd. STREET ANb NUMBER Be. APT. NO Bf. ZIP CODE 9g.IN51DE CITY LIMITS
<br />120 West 19th 68$01 ~ vES ^ No
<br />t0a. MARITAL STATUS ATTIM6 OF DEATH ~ Married ^ Never Married 10b. NAME OF SPOUSE (First, Mlddle, Last, Sufllx) If wife, glue melden name.
<br />^ Marrletl, but separated ^ WldoWed ^ blvgrced ^ Unknown
<br />Clarence Lewis Jr.
<br />11. FATHER'3•NAME (First, Mlddle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br />Orval Dewey Peters Alice Hearson
<br />13. EVER IN U.S. ARMEp FORCES? Glve dates of aervlce II yea, t4a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />(Yea, no, dr unk) No Clarence Lewis Jr, Husband
<br />15. METHOD OF p15P05ITION 18 E LMER-SIG AT 18b. LICENSE N0. 18c. DATE (Me., Dey, Yr. )
<br />~BUrlal ^DOnahon ~. ~ ~,~~' March 11, 2DD$
<br />^Crematlan ^Entombmant 18d.CEME RY,CREMATORY OTHER LOCATION CITY/TOWN STATE
<br />^Removal ^Dther(speddy) Grand Island Cemetery Grand Island, Nebraska
<br />17a FUNERAL HOME NAME AND MAILING ADDRESS (Street, CltyvrTown, State) 17b. Zlp Code
<br />Apfel Funeral Home, 1123 West Second, Grand island, NE. 688D1
<br />19. PART I. Enter the chain of avems-•dl8ee609, injwlea, or Complicati0ne••thatdirectly caUSedJhedeath. DO NOT enter terminal events ouch as cardiac arre9i APPROXIMATE INTERVAL
<br />I
<br />" ~ ~ ' ~eepirstary wreet,brrentrlCidprrybriga6en rrilAwn ahoww>A the olio:ogy,1701:p;A00)3EYIA7E.-Emer Dray-0na cause on a line. Add addltlvnal Ilnea II neceeeary. I -,._.,
<br />IMMEDIATE CAUSE: I onset tddeeth
<br />
<br />IMMEDIATE CAUSE(Flnel (a) l i'ILLl.')~frt~..~ I r ', (~.`
<br />dleeseaarcondltlvnraeuldng bUE TO, OR A3 A CONSEQUENCE OF:
<br />
<br />In death) I onset fo death
<br />
<br />9equentMllylletcandnlons,if (b) ~ I
<br />I ~ •~4NcL.L
<br />rnry,laadingtotheeaueellHed DUE TO, OR BACONS QUENCEOF: I
<br />onllnea. I onsettvdeath
<br />ErttertheUNDERLYINGCAUSE P~~
<br />(dlaaeeaorln)urythatlnlBeted (c> W~~ I
<br />t
<br />theevantaneultinglndaeth) DUE TO, ORASACONSEOUENCEOF:
<br />USF I onset to death
<br />
<br />(~ I
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<br />18. PART IL OTHER 5IpNIFICANT CpNDITI0N5-Conditions contrlbuting to the death but net resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br />~,. ~.~rn~ 1 ~ OR CORONER CpNTACTED7
<br />n ^ YES ;~ NO
<br />20. IF FEMALE: 21a.MANNEROFDEATH 2t b. IP7RANSPORTATIONINJURY 21c.WASANAUTOPSYPERFORMED7
<br />~ Not pregnant wlthln past year (~Netural ^ Homicide ^ DrlvedOperator
<br />
<br />^ Pregnant et time at death
<br />^ Accldent^ Pending Invastigatlon ^Paeben
<br />gar ^ YES 110
<br />n Not pregnant, but pregnant within 42 days of death ^ Pedestrian
<br />
<br />^ Suicide n Could not be determin
<br />ed 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />^ Notpregnan6butpregnan143d~y~totyearbefor~death ^Other(5peciryJ
<br />
<br />^ Unknown If pregnant wlthln the peat year COMPLETE CRUSE OF DEATH?
<br /> ^ YES ^ NO
<br />22e. DATE OF INJURY (MO., Day, Yr.) 22b. TIME OF INJURY
<br />m 22c. PLACE OF INJURY-At hom e, farm, street, factory, office bullding, cansiructlvn alto, etc. (5peclfy)
<br />22d.INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED ..
<br />^ YES ^ NO
<br />22f. LOCATION OF INJURY - STREET i6 NUMBER, APT. N0. CITY/~OWN SiAiE ZIP CpDE
<br /> 23a. DATE OF DEATH (Mv., Day, Yr.) =
<br />r,~ ~, 24a. DATE SIGNED (Mo., pay, Yr.) 246.TIME OF bEATH
<br />In
<br />+~ ~ ~
<br />$ ~
<br />o 23b. DATE 31GNEp (Ma., Day, Yr.) 23c. TIME OF DEATH Y= 24c. PRONpUNCED DEAD (Mo., Dey, Yr.) 24d. TIME PRONOUNCED DEAD
<br />~ 23d
<br />To the best of m
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<br />et the time, date end place 4
<br />and due to the cause(s) stated. (Signature and Title) • ~ 24e. On the basis of examinatlonand/or Inveetlgation, in my opinldn death occurred at
<br />the time
<br />date and place and due to the ca
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<br />25. DIDTpf3A000 USECONT
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<br />IBUTETOTHE pEATH7 289. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WA5 CONSENT GRANTED?
<br />rµ.
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<br />_ ^ VES ^ NO ,a1 PROBABLY ^ UNKNOWN ^ YES /~ NO Not Applicable 1128e ie NO ^ YES ~GJO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type ar Prlnq
<br />Anne K, Morse M.D. 729 N, Custer Ave., Grand Island, NE 68803
<br />28a.REGISTRAR'SSIGNATURE 28b. DATE FILED BY REGISTRAR (MO., Day,Yr.)
<br />~•
<br />I MAR 13 2008
<br />HHS-81 11/03 (55p61)
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