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STATE OF NEBRASKA
<br />~' WHEN THIS COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA MEALTMANQ„L•1JMAl~ SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINA~~,~~~1~1,,~1~E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST/L~. Tt:O ~;y1~F,U}.tH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS, R,` ~, ~ y ~ ~
<br />DATE OF ISSUANCE i ~'
<br />~~' ~ ~ 2 010 019 4 3 ~~~'
<br />LINCOLN, NEBRASKA HEwII'.FAfgN,t7sH,klA+taM~IW'3Ei~VIC~ ~•
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN seRVif~91, r~ ' ,~'ti"' ''~
<br />C:FRTIFI(:ATF OF DEATH '•. ~d~in h ~,°~~~~~~`..
<br /> 7. DEGEpENTB-NAME (First, Middle, Lsat, SuRix) 2. SEX V ,,3. TH lf~, ayat.)
<br />•
<br />~
<br /> Mar aret Marie Dillon Female `'''i ~ ~#1~,
<br />200$, -~
<br /> 4. CITY AND 8TATE DR TERRITpRY, OR FOREIGN COUNTRY pF BIRTH Sa. AGE:-Coat BlAhday Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 6.~pRTB OF'BIFtTH (Mo., Day, Yr.)
<br /> (Yro.) MOB. DAY8 HOURS MINE.
<br /> Chester, South Dakota 70 December 19, 1937
<br /> 7.8000LL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> HOSPITAL: Q Inpatient OTHER: ^ Nuraing Homs/LTC ^ Hoeplca Fadllty
<br /> 8b. FACILITY-NAME (Knot Inatltutlan, glut arrest and number) [] ER/Oulpadant ®DrcadanMs Homa
<br />~ ^ tharspe°Ityl
<br />^
<br /> 18 Via-TFivc# - , - . ,. _
<br /> Bc. CITY OR 7pWN OF DEATH (Include ZIp C°da) 8d. COUNTY OF DFATH
<br /> Grand Island B8803 Hall
<br />Z ga. RESIbENCE-STATE 9b. COUNTY ac. CITY OR TOWN
<br />$, Nebraska Hall Grand Island
<br />
<br />~p gd, BTREET AND NUMBER 9e. APT. ND. gG 7JP CODE 9g. INSIDE CITY LIMITS
<br />!€ 18 Via Trivoli 88803 ®Y•a ~ No
<br /> 1ga MARITAL STATUB AT TIME OF DEATH ®Mrrrlad ^ Navsr Man•lad 106. NAME OF SPOU8E (First, Middle, Last, Suffix) R wits, giw maiden Hama.
<br /> ^ Hamad, but asparotad [] Wldowad ^ pivoreed ^ Unknown Lar Dillon
<br />a 11, FATHER'S-NAME (Pint, Mlddls, Last, Suffix) 12. MOTHER'S-NAME (Firot, Mlddls, Maiden Surname)
<br /> Clifford Moeller Marie Oltmanns
<br />m 13. EVER IN U.B. ARMED FpRCE37 Glve dates o/ service IT Yrs. 14a. INFORMANT-NAME 146. RELATIONSHIP TO DECEDENT
<br />°
<br />~
<br />(Yaa, No, °r Unk.) NO
<br />Lar Dillon Husband
<br /> 18. METHOD OF DISpO81TIpN 16a. LMER-SIGN Rj
<br />~ 18b. LICENSE ND. 18c. DATE (Mo., [Hy, Yr.)
<br /> ®nan.l ^geneuen ( ~ Ma 15, 2008
<br /> ^cmmauan ^¢ntamum.nt
<br />^k.moval [~OanrlBpecity)
<br />18d. CEMETERY, CREMATORY OR OTHER LDCA N CITYROWN 8TATE
<br /> Westlawn Memorial Park Cemetery Grand Island Nebraska
<br /> 77a. FUNERAL HOME NAME ANA MAILING ADDRESS (Street, Clty or Town, Stem) 176. Zip Coda
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 88801
<br /> CAUSE OF DEATH See instructions and exam lee
<br /> u. paltr i. emir tree chdn orsvrsat - dleeewe, IMudae, or compllwtlom-Ilia directly eaaus tree dsah. DO NOT abler terminal awnta ouch u urdlec arras, APPROXIMATE INTERVAL
<br /> napiratary arrrp, or wrlMCUlaf abr111erlen wehour ahawinq tM stlolepy. DO No7 AYBR@VIATE. Einar only oM coup on a Ild. Atla aa0alonal IIMa k MCNNry.
<br />I
<br /> onset to death
<br />IMMEDIATE CAUSE:
<br /> IMMEDIATE CAUSE (Final
<br /> disease or c°nalllon roaulfing a) natural cause I '
<br /> m a.atn)
<br /> DuE TD, oa As a i;ptiss4uERGE DFi - - . _ .... ._ . _ _ . _ ._ _. __ ... _. _ . I an..t to a.am
<br /> Saquandally Iiat candltl°na, If b) I
<br /> arty, leading m the cause Ilshd
<br /> °^ tins a. DUE TO, OR AS A CONSEQUENCE OF: onset m death
<br />I
<br /> Enter the UNDERLYIND CAUSE c) I -
<br /> (dlasaaa or injury that i^Itiatad
<br />the evanq rsaulting In death) pUE 7D, OR AS A CONSEQUENCE pF: onaat to death
<br />I
<br /> LAST
<br />I
<br /> a)
<br /> 18. PART IL OTHER SIGNIFICANT COND1710N3-Conditl°na conmbuting td the death but not raaulVng in the undedying cause glwn in PART I. 1s. WAS MEDICAL E7(AMINER
<br /> OR CpRONER CONTACTED?
<br /> ® YE8 ^ ND
<br />
<br />IK
<br />W
<br />2g. IF FEMALE:
<br />21 s, MANNER OF DEATH
<br />21 b. IF TRANSPORTATION INJURY
<br />21 c. WAS AN AUTOPSY PERFORMED?
<br />LL
<br />r
<br />®Not pregnant wlthln past you
<br />~ Natural ^ Homtclds
<br />^ DdvarlDperat°r
<br />^ YES ®NO
<br />U~j ^ Pregnant at time of death ^ Accldmt ^ Pending Invaatlgatlon ^ Passenger 27d. WERE AUTOPSY FINDINp3 AVpJLABLE
<br />V ^ Not prognant, but prognant wlthln 42 days oT death ^ Suicide ^ Could not be determined ^ Padeatrlan TO COMPLETE CAUSE OF DEATH?
<br />~] ^ Nol prognant, but pregnant 43 days to 1 year before death ^ Otner (Specify) ^ YES [~ NO
<br /> ^Unknown IT prognant wlthln the pant year
<br />a
<br />E
<br />22a. DATE OF INJURY (M°., bry, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY-wt home, Tsrrr>, street, tottery, Dints 6ullding, construcban site, ate. (Speciry)
<br />0
<br />V
<br />at
<br />m
<br />22d. INJURY AT WpRK7
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />O
<br />
<br />^YE8 [] NO _
<br />~ .... ..
<br /> 22f. LOCATION OF INJURY • STREET b NUMBER, APT. NO. CITYlTOWN STATE ZIP CODE
<br /> 29a. DATE OF DEA7M IMo., Day, Ya) 24a. DATE aiGNED (Mo., Day, Yr.) tab. 71ME OF DEATH be twee n
<br /> .~~ ~~~ Ma 15 2008 .10:45 m & 8:57 a m
<br /> 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />236. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF pEATM ~ ~ ~
<br /> ~
<br />>•
<br />Eaz m E~ax am
<br /> ~ ~ ~ 23d. 7o the bast of my knowledge, death occurred et the time, data and place ~ W ~ ~ ~. On the bull of axaminagon and!°r inveatigallon, in my opinion death xcurred
<br /> a ~ and due to the cauaa(s) amtad. (SlgnaWn and Title) ~ O ~ s pine, data ^ place a due to the cau~e(a) fated. (Signature d Tltls)
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<br />Ha~~
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<br />y
<br />~ r ~~ ~~
<br />~~4~
<br /> >
<br />~o ount Attorne
<br /> 26, bID TOBACCO USE CONTRIBUTE Tp THE DFATH7 28a. HAS ORGAN DR TISSUE DONATION BEEN CON81pERE07 28b. WA$ CONSENT GRANTED?
<br /> ^ YFtB ^ NO ^ PROBABLY ~] UNKNOWN ^ YES ~] NO Not Applicable K tea la Np ^ YES ^ NO
<br /> 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSIGIAN, CpRDNER'S.PHYSICIAN OR GOUNTY ATTORNEY) (Type or Pdnq
<br /> Robert J. Cashoili, Deput Hall Count Attorne 231 5. Locust St. Grand Island NE 68801
<br /> 28a REGISTRAR'S SIGNATURE 2gb. DATE FILEb BY REGISTRAR (Mo., Pay, Yr.)
<br />P ~aY ~ 7 Zoos
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