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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA pEPARTMENT OF HEALTH ~4N0 HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA Q.~P,~AIalTpglElllTQF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR-~I'Pfl~~'}}~~EGt?R0.5, ...y, ' ~
<br />DATE OF ISSUANCE ~ O ~ O O ~ r, ~ ~ '
<br />r'~ J _
<br />APR 1 ~ 201 ~- ~r,~N4~ ~ ~~~ J ~ 1r„
<br />d~ ~ • ~n H,~~~ y'
<br />LINCOLN, NEBRASKA ~/ ~`~I "~7, ':` ~ r'• , -;... ~
<br />N
<br />STATE OFNEBRgSKA-DEPARTMENTOFHEA4THANOHUMANSERYICESFINANCE~I~USUF;PpRS '~~
<br />rFnrrrll+ere nr nrwru I1C 77 C C C
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<br />
<br /> 1. RECEDE NT'S•NAME (Flral, Mltltlle, Laal, SYIIir) 7. yE% y. DATE OP DEATH (Ma, Dey, YI.)
<br /> 14ax • dward• 2006
<br /> /~ CITY ANp STATE OR TERRITORY. OR FOREIGN COUNTRY DF BIRTH Sp. AOE•Le51 BDMtlay Sb. UNDER 1 VEAq SC~ UNDER 1 pAY x.,
<br />B. DATE OF BIRTH IMq., Dey. YLI
<br /> (Yr,.) MOS. DAYS HOURB MINE.
<br /> Grand Island, Nebraska 9p December 13, 1915
<br /> >. SOCIAL SECURITY NUMBER B4 PLACE OF pEATH
<br /> 50b-09-5662
<br />N0571YU ~ Inpalianl. (~$ ~ HurMrq NgrIWV7C ^ Hocpica Fnclllty
<br /> B0. FACIUTV•NAME pl nul insllmudn, glra atroal and number)
<br />4 EWOulpallem ^ Oaoidem'aHDma
<br />~ Grand Island Veterans Home
<br />a 2300 West Ca ital Avenue ^ ~ ^OI++~IBP~DYI
<br />~ aD. CITY OR TOWN OF DEATH Ilncldd/Zlp Cddel ad. COVNTV OF DEATH
<br /> Grand Island Nebraska 68803 xall Count
<br /> 8a RESIDENCE-STATE %,COU-RY 9p CITY ORYOWµ
<br />~, Nebraska Nall Grand Island .
<br />~ Po. STFIEET AND Nl1MBER 81. APT. NO 91. Zlp CODE Bq.INSIDE CITY LIMITS
<br />•5 2300 We_at Capital Ave. 68803 L1 YES ^ No
<br /> t0i. MARITAL STATUS AY TIME OF DEATN ~Merfldd ^ Narer MAPoed 106. NAME OF SPOUSE (Flrsl, Middle. Lasl, SuNip II will, give maiden nem/.
<br />n ^Marrled,bulseparalvd dWldhwed ODirgrHd ^Unknown
<br /> ~QLL~.fie Hoffman
<br /> I1. FATHER'S•NAME (Flrel. Mrtlel/, La,l, Sulllyl 12. MOTNER'8-NAME (Fuel, Mlddle, MAiden Surnemal
<br /> Glen Miner Gertrude McVey
<br />
<br />yD. EVER IN V.S. ARMED fOACES'! Olre dales pt servkl a yea. _ ... __.
<br />1 aa.INF ORMANT-NAME
<br />110. R E uT ION5HI P TO DE CE DE NY
<br /> (rel, nd, drunA.l Yes: 1-10-44 1-15-46 Louise Miner Wife
<br /> f5 MFYNODOF DISPOSrT10N IBa.EMBALMER.8ICNATURE 16D~LICENSE NO. 16q. DATE IMp., DaY. Yr,)
<br /> I]8urlal ^DpnnlDn Not Embalmed July 10, 200fi
<br /> ~Cremallon Q Enrpn6manl IBd. CEMETERY, CREMATORY DR OTHER LOCATION GITT I MOWN STATE
<br /> gRwmwar polher(spicily)
<br /> Westlawn Memorial Park Crematory Grand Island, NE.
<br /> 17a. FUNERAL NOME NAME AND MAILIND ADDRESS IStreeL Cdydr Ypwn, 8nta) 176. Zlp Cpda
<br /> Apfel Funeral Home, 1123 West Second, Grand Island, NEn 68801
<br /> CAU F DEATH (ee inatructlona and examples)
<br /> 1fl pARTLEMerthOChalnalevenr,••dl,Nava.Inlmiee,grCDmplicaligna••Ihlldlretllycaundmedlam.pQNOTenrerlerminpiYenls,ughucardiaparq,l, APPRD%IMATEINTERVAL
<br />I
<br /> reapiralgry arrlil, p rmlrrcWu Il6dllllipn wirhpul ahpwinq qIe allalggy. DO NOT ABBREVIATE. Enlar only one uule m a Ilnl. Apd lddiripnp IinH it Ncasaary. I
<br /> _.._ _ .... _.__. 1.61M~RIATF#9AUaa:- . _.._ . _._.. Y. _. , _ .... I
<br />pnfil lp death
<br /> aaMEDWTECAUBE(F'NW W Res irat0 Failure ~ 4 tie s
<br /> di,waaamtliupupuKNq DUE TO, OR A$ACONSEOUENCE OF: I meal to death
<br /> aldenN I
<br /> s.RlranBepynnwndNenl,r nn Pnetxronia q Days
<br /> any, yadlnq lomreaur lhWd DUE TO.OR ASACONSEOUENCE OF; I pnwno tlealn
<br /> qp llMa•
<br /> EMarIMUHDERlYB1GCAV8[ I
<br /> Idlraaaa Miury IMI NY6epd (Cj I
<br /> IMw,ma AauOagMdrWO DUE TD. DR ASACONSEOUENCEOF:
<br />L,gy I pnsal to deem
<br />I
<br /> (~ I
<br /> IB. PART IL OTHER SIGNIFICANT CONOIYIONS~CDndiriDp9 CdningWinq lO Nl dealR Oul nql rodullinq in ml UndBrlylnq CauSi given In PART I. t9. WA5 MEDICAL E%AMIHER
<br /> Dr~nta.a, (~17~, Dysphagia. ORCORpNERCONTACTED?
<br /> Q YES ~ ND
<br /> 20. IF FEMAL E; 21a. MANNER OF pEATH ZIp. IF TRAN&PORTATION INJURY 2t C. WAS AN AUTOPSY PERFORMED?
<br /> ^Nulpnpnam wilnin pap yver ~Ninral ^Hprcrigida ll OriwvOpuaNx
<br />
<br />^ YES ~[] ND
<br />^ Pregndnl wt lime DI deem 'J Accldenl'a Pending InvaeYigalipn p Pa55enger
<br />
<br />a ^ HM pregnant, 0u1 pregnam wllnln q2 Da S dl deem d PedesUian 21d~ WERE AUTOPSY FINDINGS AVAILABLE TO
<br />Y C75uicipi r7 Cwld ngl6a delnmined
<br /> ^ Nd prapNnl, bur pregnant /3 dayf b 1 year 6atgre death
<br />^OIMr(Spetily) COMPLETE CAUSE OF DEATM
<br /> l7 unkrmwn it pregnant wllhln the peal year ^ YES ^NO
<br />Ea
<br />CT ...._
<br />22,. DATE OF INJURY (MO.. Day, Yr.) 22D. TIME OF INJURY 22q. PLACE OF INJURY•AI home, farm, strait, lanpry, office Duildinq, cpnslrucllpn d19, 61c. (Spicily)
<br />
<br />0 m
<br />~ 22d.INJURY AT WORK? 2Ze. DESCRIBE HOW INJURY OCCURRED
<br /> ^ YE8 ^ NO
<br /> 2Zr.LOCAT10NOFINJURY•STREET8NUM8ER,APTNO. CRTROVIN STATE 'ZIP CODE
<br /> 77A TE OF DaATN IMd., Dey. Yr.l ~ .. ..--.. Pa,. DATE $IONED (M0..Dq,Trj. 2A~TBdE OP pEATK- - _.-..___,
<br />~
<br /> 3' July 9, 2006
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<br />y
<br />= July 5iDN ~D fZoD, DOay, Yr.) 27q]TIZE ~ODEA7HP
<br />3~s 2ac. PROMOUNGEDDEAp IMp„Day,Yr.l Zad.TIME PRONOUNCED DEAD
<br />€ SS
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<br />• TTI
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<br />ZBd. ip ma bl5101 my AdgrMdgl, Oewlh p[CURetl AI mi lima. Data aro plats ° ~ ~ 2/a. On the haws pl eCemine6an antl/Or inyiSligalipn
<br />In my npmmn deem dCCUrtld i1
<br /> ,
<br />E
<br />a g and dui Id the tau qe) Sliledr/and Tills) ry a as mo rimo, dale dnd place and due Ip Iha uueap) elaleq. ISignarure pM Tine 1 •
<br />
<br /> 25. DID TOBACCO USE CgNTPIBVTEt HE DEATH7 a. HA ORGAN OR TISSUE pONAYyON BEEN CONSIOERED7 26b-WAS CONSENT GRANTED?
<br /> ^ YES ^ NO ,~ROBABLY ^ UNKNOWN ^ YE6 NO NOI AppIICi01i i126a i%NO '] YES ^ NO
<br /> Z7. NAME, TITLE ANDADDRESSOFCERTIFIER (PHYSICIAN CORONER'SPHY5ICIANOR000NTYArYORNEY) ITypeaPrinq
<br /> T4.A. Tarl~kins, M.D., Grand Island veterans Hone, Grand Isl.arid, tdE 68803
<br />2Ba.REGISTRAR'551GNATURE 2Bh. DATE FILED BY REGISTRAR (Mp.. Day. Yr,l
<br />,~ JUL 1 3 20p6
<br />HHS•61 11/03 (55061)
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