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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEA;E~"Fi qND FIUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA;~K.q'~D~'PA,R,TM~NT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORYFD/~"~/"I`y-At' 17~'~DRDS:•
<br />~ • I
<br />DATE OF ISSUANCE J ~
<br />r ~
<br />OCT 0 6 2008 ~ O ~ ~ O A + O n ~ `~~$IS~N}7"~~'J'"~t ~EGISPRAR
<br />~f 1 a ~ARTMENT QFHEALFy"AND
<br />LINCOLN, NEBRASKA +~ ~ F~,IM,4I,V SEktVl~'ES
<br />STATE OF NEBRAS C - DEPARTMENT OF HEALTH ANA HUMAN ~R~~S • • .. , : ' ,~-Q , . ,~ 9 O
<br />1. DECEDENTS-NAME (Flnt Middle, Last, Suffix) 2. SEX 3bD T^ dF DEA7N (Mo.,Day,YrJ
<br />2
<br />Duane Edwin Donaldson Male Se tember~2008
<br />A CITY AND STATE OR TERRITORY, pR FOREIGN CpUNTRY OF BIRTH ea. AGE-Last Birthday Bb, UNDER 1 YEAR 8c. UNDER 1 DAY B. PATE OF BIRTH (Mo., Dey, Yr.) •
<br />(Yrs.) MOS. DAYS HOURS MINB.
<br />Albion, Nebraska 61 January 11, 1947 '
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />~ 508-BO-5168 HOSPITAL: ^ Inpatlant OTHER: ^ Nuroing HomrlLTC ^ Hosplcr Fadlity
<br />Bb. FAGILITY-NAME (If not Inatltutlon, give street and number) ^ ER/Outpatlrnt ®Dacadent's Hornr
<br />1012 E. Oklahoma 5t. ^ DDA ^ ou,er(sp.alty)
<br />0
<br />Bc. GITY OR TOWN OF DEATH (Include ZIp Cad.) ed. COUNTY OF DEATH
<br />Grand Island 68801 Mall
<br />'Z aa. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TgWN
<br />Hall Grand Island
<br />~, Nebraska
<br />ed. STREET AND NUMBER Be. APT. NO. 1K. 7JP GODS ag. INSIDE CITY LIMITS
<br />.e 1012 E. Oklahoma St. 68801 ®ves ^ Na
<br />~ 18a. MARITAL STATUS AT TIME OF DEATH ®Marrlad ^ Never Married 10b. NAME OF SPOUSE (Flat, Mlddla, Lest, BufRx) If wlfa, give maiden name. -
<br />^ Married, but eeparetad ^ Wldowad ^ Dlvorcad ^ Unknown Llnna Dee Rogers
<br />~. 11. FATHER'S-NAME (First Middlr, Laat Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br />Charles Donaldson Helen Cli store
<br />ro 14b. RELATIONSHIP TO DECEDENT
<br />m 13. EVER IN U.S. ARMED FORCES? Glva dates of service I} Yae. 74a. INFORMANT-NAME
<br />~ (raa, Na, ar unk.) Yes 06/23/1968-D5/21/1971 Linna Dee Donaldson Wife
<br />18. METHOD OF DISPOSITION 18a. EMB NATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr,)
<br />^edn+I (aD•nuloa lL'l ,,J c~ /~~ 7 5e tember 30, 2008 -
<br />®Crcmenvn ^entvmtvmnt STATE
<br />^rt+movsl ^gtmdsp•cxy) 18d' ETER , CREMATORY OR OTHER LOCATIDN CnYITOWN
<br />Central NebraskR Cremation Service Gibbon Nebraska
<br />17a. FUNERAL HgME NAME AND MAILING ADDRESS (Street, Clty ar Town, State) 17b. ZJp Cods
<br />All Faiths Funeral Marne, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See instructions and exam lee
<br />++. TART 9. Enar 4+e ~iet,° °r Qy~Jy -:~1sse*ea, iryude., ar compncaNone. thnt dlncuy caused rna d•eth. Do NOT.nrer rermin.l w•nes.uen .. e.rdlee +m.e, APPROXIMATE INTERVAL
<br />n+piruory+rrut Yr veMdculu fl6dll+uvn wa11+W fhvwing df• etlDlopy. b0 Na7 ABBREVIATl. Elri•r only one caub on a Iin•, Add eddxlonal Iimf N nec••ury. f
<br />~IMMECIA7E CAUS /^~ /~; i onagt tobt~`.q~ O J,
<br />IMMEDWTECAUSEIFinal ~~~,ep \ ( _ O ~ -^ / ,„ -,. i•. ~y _! ~ I ` +'•r
<br />dlsaaae or condition rosulting a) g/'O y W S J ~/ ~. `.~tie3 , 1 ~( .Y\. (S~ J(rR~ .Y' L~( tt-~- I
<br />In death)
<br />DUE TO, OR AS A CONSEOUENGE DF: onset to sath
<br />~~
<br />$equan8ally Ilat condltlona, If b) I
<br />any, leading to the cause Ilsted
<br />on line a. DUE TO, OR pS A CON$EgUENCE OF: onset tb dsalh
<br />I
<br />Enter the UNDERLYING CAUSE c) ~ I
<br />(dlseaae or InJury that Initlatad onart to depth
<br />the events rosulting in death) DUE TO, OR AS A CONSEpUENCE OF: I
<br />LAST I
<br />d) ~'
<br />18. PART ii, OTHER SIGNIFICANT CONDITIONS-Canditlane contHbuting to the death but not resulting In the undrdytnp cause glean in PART 1. 19. WAS MEDICAL EXAMINER ,.
<br />OR CORONER CONTACTED?
<br />^ YE9 ~ NO
<br />20. IF FEMALE: 21 e. MANNER OF DEATH 216, IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />LU
<br />LL
<br />~ ^ Not prognent wlBlln past year ^ Natural ^ HorMcida ^ DdverK)peretor ^YES NO
<br />W ^ Pregnant at Ums of drrdl ^ Accldenl ^ Prnding Invsadgadon ^ Passenger 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />C1 ^ Not pregnant, but pregnant wlthln A2 days o} death ^ Suicide ^ Could not be datermined ^ Pedestaan TD COMPLETE CAUSE OF DEATH?
<br />^ No! pregnant, but pregnant 43 days to 1 year before death ^ Other (SpaclTy) ©YES ^ NO
<br />^Unknown If pregnant wilhln the past year
<br />d
<br />a
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME Or INJURY 22c. PLACE OF INJURY-At hems, farm, atroet fsctory, oTncs building, conatructlon she, etc. (Specify)
<br />r7 22a. INJURY AT W RK7 22a. DESCRIBE HOW INJURY OCCURRED
<br />~ ^YES NO
<br />22f, LOCATION OF INJURY -STREET 8 NUMBER, APT. NO. CITYI70WN STATE ZJP CODE
<br /> 23a. DATE OF DEATH o., Day, Yr.) (~
<br />~ Z 24a. DATE SIGNED (Mo., Pay, Yr.) 24b. TIME OF DEATH
<br /> ,
<br />,~~ /
<br />a ~ ~,~~ m
<br /> ~ 22b. DAT S NED (Ma., Day, Yr.) 2Sc. TIME OF UEpTH ~ Y O 24c. PRONOUNCED DEAD (Mo., Dry, Yr.) ytd. TIME PRONOUNCED DEAD
<br /> a.~.}, {( at~ ~~6 ~ m
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<br />d
<br /> 27d. To thr best oT my kno dge, daa ccurred al the time, data and place
<br />d Title)
<br />SI ~ W Z 24a. On the brsis of axaminadan andlar Invaatlgrtion, In my opinion death occurre
<br />at the time, dale and place and due to the cause(s) stated. (Signature and ]Iris)
<br />a G
<br /> n ure an
<br />a and duet a ca ee( fated. ( o
<br />
<br />
<br /> 28. DID TOBACC USE CONTRIBUTE 70 THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION DEEN CONSIDERE07 28b. WAS CONSENT GRANTED]
<br />E
<br />^ NO
<br />^
<br /> ^ YE$ ~ND [] PROBABLY ^ UNKNOWN ^YES ~ NO Y
<br />S
<br />Nof Appllca6lr H 28a Ia NO
<br /> COF~INER'S PHYSICIAN
<br />2~ NA E. TITLE AND ADDRESS OF CERTIFIE Pr~IA
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<br />~ OR COUNTY ATTORNEY) (Type ar Print)
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<br />28a. REGISTRAR'S SIGNATURE
<br />~,~~~,..
<br />,( ~~ 286. DATE FILED BY REGISTRAR (Ma., Day, Yr.)
<br />~Cr x zoos
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