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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF MEAG~M 7~~f-l~~lN1~{N ~~R.VICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY pF THE pRIGINAL RECORb pN FILE WITH THE NEBR,4SIC~"7DE,~4~~~I~Ef~IT O~ fil~ALTH,9ND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VZ1~A~~VR~;GOl7D3~.. ~ ,.
<br />~ J ~"
<br />DATE pF ISSUANCE ~/ y~ , ~r '
<br />STANLEY S. ~QG1F'~R
<br />12/24/2009 2 010 U 3 E 61 ASS7S7'A'aV7`'~;~A Fi~GI~T~RAR '
<br />DEPAF~~MENT OF hlEALTH-ANI~ . ~ '
<br />LINCOLN, NEBRASKA HUhiAltf-~FR~IrICES
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<br />STATE QF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES ,~',., .: t r ~ .-..09 030Q6
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<br />CERTIFICATE OF DEATM ~ `~
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2, SEX ', 3. pA E OF pf:ATH (Mo., Day, YrJ
<br /> Elsie Mildred Purvis Female "December 16, 2D09
<br /> 4. CITY AND STATE OR TERRITpRY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday b. UNDER 7 YEAR 5c. UNDER 1 DAY 8. DATE pF BIRTH (MO., Day, Yr,)
<br /> (Yrs.) MOS. DAYS HOURS MINE.
<br /> Massena, Iowa 95 February 9, 1914
<br /> 7. SOCIAL SECURITY NUMBER ea. PLACE OF DEATH
<br /> 505-44-2968 J~O$PITAL ^ Inpatient THER ^ Nursing Home/LTG ^ Hospice Facility
<br /> 86. FACILITY-NAME (If not Inatltutlon, glue street and number) ^ EWOutpatlent ®DecedenNs Home
<br />
<br />~
<br />U 304 West 12th ^ DOA ^ Other(SpecHy)
<br />W ec. GITY OR TOWN OF DEATH (Include Zip Code) ed. COUNTY OF DEATH
<br />© Grand Island 68801 Hall
<br /> 8a. RESIDENCE-STATE 96. COUNTY 9c. CITY OR TOWN
<br />z Nebraska Hall Grand Island
<br />LL 9d. STREET AND NUMBER e. APT, NO. 9f, ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 304 West 12th 68$O1 ®YES ^ NO
<br />.~ 10a. MARITAL STATUS A7 TIME OF DEATH ^ Married ^ Never Married 70b. NAME pF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name
<br />d
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<br />^ Married
<br />but separated ®Wldowed ^ Divorced ^ Unknown
<br /> ,
<br /> 77. FATHER'S•NAME (First, Middle, Last, Suffix) 12. MpTHER'S•NAME (First, Middle, Malden Surname)
<br /> George Brawe Anna Campen
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<br />E 19. EVER IN U.S. ARMED FORCES? Giva dates of service IT Yes. 14a. INFORMANT-NAME 146. RELATIpNSHIP TO DECEDENT
<br />s (Yes, No, or unk,) No Gary Purvis Son
<br />~ 15. METHOD OF DISPOSITIpN i8a. EMBALMERSIGNATURE 18b. uCENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />H ®Burial ^ Donation
<br />Tracey Dietz
<br />1328
<br />December 21, 2009
<br /> ^ cremation ^ Entombment
<br />
<br />^ Removal ^ Other (Specify) 18d. GEMETERY, CREMATORY OR OTHER LOCATION CITY! TOWN STATE
<br /> Westlawn Memorial Park Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, State) 17b. Zlp Cods
<br /> Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br /> F DEATH See instructions an exam es
<br /> 19. PART I. Enter the chain of events--diagaaea, Injuries, pr compllcatipna•that dlredly caused the death. DO NOT enter terminal events iucN ai Cardiac arrest, ; APPROXIMATE INTERVAL
<br /> resplre[ory arroat, pr ventricular 9bdllation without shpwinq the etiology. DO NOT ABBREVIATE. Enter only one Cause qn a Ilne. Add addltlonal Ilnes ii necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Figdl a) Advanced Age ; 90 Years
<br /> disease or condNlon resulting
<br /> In death( DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Sequentially list conditions, It b)
<br /> any, leading to the cause listed
<br /> on Ilne a.
<br />DUE TO, OR AS A CONSEQUENCE OF: ; onset tq death
<br /> Enter the UNDERLYING CAUSE C)
<br /> (diieaae Or InJury that Initiated
<br /> the events resuNlnq In death) DUE TO, OR AS A CONSEQUENCE DF: ~ Onset to death
<br /> LAST d)
<br /> 18. PART II, OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given In PART I. 79, WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br />~ ^YES ®NO
<br />W 20, IF FEMALE: 27a. MANNER DF pEATH 21 b. IF TRANSPORTATION INJUR 21 c. WAS AN AUTOPSY PERFORMED?
<br /> ^ Not propnant within peat year ®Naturol ^ Homicide ^ DAverlOperetor
<br />
<br />U
<br />^ Pregnant at time of death
<br />^ Accident ^ Pending Invastlgatlon
<br />^ Passenger ^YES ®NO
<br /> ^ Not pregnant, but propnant within 42 days pfdeath
<br />^ Suicltle ^ Could not be determined ^ Pedeatdan 27 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />
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<br />^ Nat pregnant, but pregnant 49 days to t year beforo death
<br />^ Other (Specify) TO COMPLETE CAUSE OF DEATH?
<br />~ ^ Unknown If propnant within the past year ^YES ^ Np
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<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />s
<br />~ 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />O
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<br />^YES ©NO
<br /> 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITYlTOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.)
<br />~ 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME DF DEATH
<br /> ~ W December 16, 2009 ~
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<br /> 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME pF DEATH ~ `~~' ~ „ 24c. PRONOUNCED DEAD (MO., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> E z December 23, 2009 09:40 PM ~ a ~ Z~Z
<br /> O 3d. Tp the bert of my knowledge, death occurred st the time, dab and place
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<br />o 24e. On the basis of examinitldn endloY Invastigatlon, In my opinion death occurred at
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<br />p the time, date and place and dub tq the pause(s) aWted. 181gnature and TItl6(
<br /> David R. Colan, MD ~ ~
<br />. _..x ._ ... ,,u,~, .._.. ...... _ . -, , _
<br /> 25. DID TOBAGCO USE CONTRIBUTE TO THE DEATH? 288. HAS ORGAN OR TISSUE DONATION BEEN GONSIDERED? 286. WAS CONSENT GRANTED?
<br /> ^ YES ®NO ^ PROBABLY ^ UNKNOWN ^YES ®NO Not Applicable iF 28a is NO ^YES ^ NO
<br /> 2 1 D I ( H I A 1 ) ype or riot)
<br /> David R. CDlan, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE ' '' 28b. DATE FILED BY REGISTRAR (Mo., Day, Yc)
<br /> December 23, 2009
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