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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALT,Nh~/Vp l;'1IJM,AN,"'alE~'~/ICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRgSKA ,~PAf2TJl1k1V'1' QF'hI~ALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VI7}#L ~Rr~C(3RC~S, I • ' ,
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<br />DATE OF ISSUANCE ~.!
<br />q {~ (] STAN~.~Y S~. OOPFR . , ~ .,,
<br />MAR O O ZOta 2 O~ O O 5~ 3 V ASSTSTAN7~ ~'rAT~ RE~FSTRA6t- y ''
<br />DFPAfRTp1ENT OF HE~L,7 H A/Vb,' ;;,
<br />LINCOLN, NEBRASKA _ .... HUMpf~ S~'I~W~'C~5 1 '~~•: '
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<br />STATE OF NEBRASKA - DEPARTMENT QF HEALTH AND HUMAN SERVICES ; ~„~ Q • • ~ ~ ~ ~.~ « ~~
<br />C:FRTIFIC07F t7t= ~FATH I~+ .
<br />1. DECEDENTS-NAME (First, Mlddle, Lart, Suffix) 2 SEX 3: Dl,)T~ OF Fr1TH (Mo..,J1ay,Yc)
<br />Marie M rtle Lane Female Februa 2fi, 2010
<br />4. CITY AND STATE OR TERRITORY, pR FOREIGN COUNTRY OF BIRTH 5a. AGE•Last Birthday eb. UNDER 1 YEAR Bc, UNDER 1 DAY 8. DATE DF 81RTH (Mv., Day, Yr.)
<br /> (Yre.) MOS. DAYS HOURS MINS,
<br />Bassett, Nebraska 90 October 3, 1919
<br />7. SOCIAL SECURITY NUMBER ea. PLACE OF DEATH
<br />507-fi4-7976 b08PI7AL: ®Inpatient ~1ER~^ Nuninq HomeILTC ^ Hoeplce Faculty
<br />Bb. FACILITY-NAME pf not Inedtudon, give street and numWr) ^ ER/Outpadent ^ Decadent4 Home
<br /> ^ ooA []Othar(Specify)
<br />slot Franr~is Medical Center
<br />ea CITY OR TOWN OF DEATH (Include Zlp Coda) Bd. COUNTY OF DEATH F •
<br />Grand Island 68803 Hall
<br />9a. RESIDENCE-STATE Bb. COUNTY 9c. CITY pR TOWN
<br />Nebraska Hall Grand Island
<br />9d. STREET AND NUMBER 9e. APT. NO. 9T. ZIP CODE 9g. INSIDE CITY LIMITS
<br />1823 North Park Ave 68803 ®r.a ©N~
<br />10a. MARITAL STATUS AT TIME OF DEATH ®MaMed ^ Nsvsr Married 186. NAME OF SPOUSE (Plot, Mlddle, Laat, Suglx) N wife, glue maldsn name.
<br />© MaMed, but sepantad ^ Widowed ^ Divcrcea ^ unknown Laurence Jacob Lan e
<br />11. FATHER'S-NAME (Pint, Mlddle, Lase SufRx) 12. MOTHER'S-NAME (First, Mlddle, Malden $umeme)
<br />Harold Gilbert Ammon Addie Amanda Welton
<br />13. EVER IN U.B. ARMED FORCES? Give dates of service If Yea. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />(r.a, No, ar Unk.) nJp Laurence Jacob Lane Husband
<br />18. METHOD OF DISPOSITION 18a. E LMER$IGNATjDR 18b. LICENSE NO. 18c. DATE (Mo., Day, Ye)
<br />®ead.l ^°°aal°a ` w~ / ~ / / March 2, 2010
<br />^Cmmatl°n ^Ela°mkxnent
<br />^RamovAl ^OM.dep.°svl
<br />18d. LMETERY, GREMATORY OR OTHER L CATION CI7YlTOWN STATE
<br /> Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRE8S (Street, City ar Town, State) 176, Zlp Cade
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See instructions and exam lea
<br />1a. PART I. lMer etN Che1n orerenA - dINiN., Inf od.., °r °°mplltatlonh tMt tllrrdly °ruNd Mt d.ah. DO NOT saner Nmdml mmr futh Y unisC ama4 ~ APPROXIMATE INTERVAL
<br />nrplretvry emaL or vmrlcmu nbnllallen without shvwlna the eaela(ty. bo NOT AB6REVIATE. Enter vnty ens auq vn . IIM. Ave aeani°nrl Ilnn k mcearary. ~
<br />IMMEDIq E CAUSE: ~ ~ onset ro d ath
<br />IMMEDIATE CAUSE (Final J r] t
<br />dlsaaee or condition resulting a) f
<br />! ~/ j/ ~! J
<br />~
<br />I
<br />in death) YW ~ - ! -
<br />DUE T0, OR AS A CONSEQUENCE OF: ~ onset ro death
<br />8equemlally Ilat condlNon; H I
<br />b) i
<br />any, leading tv the cause noted
<br />on line a. DUE TO, OR AS A CONSEDUENCE OF: ~ onset to death
<br />I
<br />I
<br />EMerthe UNDERLYING CAUSE c) ~
<br />I
<br />(disease ar InJury ffiat initiated
<br />the svanta naulting In death) DUE TO, OR AS A CONSEQUENCE OF: ,onset to death
<br />LAST ~
<br />I
<br />d) ~
<br />78. PART II.OTHER SIGNIFICANT CONDITIONS-Conditions conMbutinq to the death but no! nsulting In the undedying cause given in PART I. 79. WAS MEDICAL EXAMINER
<br /> OR CORONER CO TACTED7
<br /> ^ YE3 ND
<br />20. FEMALE: 21a ANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY P~RFORME07
<br />of pregnant within past year Natural ^ Homicide ^ Ddver/Operatar ^ YE$ •W, ,N(O
<br />^ Pregnrnt at time of death ^ Accidem ^ Pending Invastigagon ^ Passenger
<br />
<br />^ Not pngnant, but pngnant within 42 days of death
<br />^ Sulclde ^ Could not be determined
<br />^ PadaatHan 21d. WERE AUTOPSY FINDING8 AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />^ Not pngnant, but pngnant 4° days to 1 year before death ^ Other (Spacgy) ~ YES •Ly, /NO
<br />^Unknown If pregnant within the peat year
<br />22e. DATE OF INJURY (Mo., Day, Yr.) 22b~ TIME OF INJURY 22c. PLACE OF INJURY•At home, Tartu, street lactvry, rHnp bonding, conaWCtlnn aim, eta (Specify)
<br /> m
<br />22d. INJURY A7 WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />^ YES ^ NO
<br />2X.'tA7CATIONOFINJURY-BTREETANUMBCR,-APT. NO:~•.~...,_"•.-.-~'.•.'`. ...--" .... ......... .~°-'STATL"•"_.._._. --.. ....21PCODE..
<br />23a. DATE OF DEATH (Mv., Pay, Yr.) ~ 24a. DATE SIGNEO (Mo., Day, Yr.) Rob, TIME OF DEATH
<br />~'~ February 26, 201 0 a sty m
<br />23b, DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF OEATH ~ ~ O 24c. PRONOUNCED BEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
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<br />Roe. On the bawls of examinagon andlor invatigatlon, in my opinion daeth occurred
<br />29d. To th t y know edge, ath cecurred at the time, dam and place
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<br />p ue th ause( at (Slpnatun an ~ ~ ~ at the time, dam and place and due tv the cause(s) s4tad. (Blgnaron and Title)
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<br />~ 25. DID TO AC E CONTRIBUTE TO THE DEATH? RBa. HAS pRGAN OR TISSUE NATION BEEN CONSIDEREDT 28b. WAS CONSENT GRANTED?
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<br />
<br />^ YE O ^ PROBABLY ^ UNKNOWN
<br />^ YE8 NO ~~
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<br />Nat Applicable H 28a Is NO ©YES L./^~•'
<br />R7, NAME, TITLE AND ADDREg3 OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typo or Print)
<br />Wagoner, ,john A.,M.D. 8 Al ha Sf; Grand Island NE 68803
<br />Rea, REGISTRAR'S SIGNATURE " `_- 286. DATE FILED BY REGISTRAR (Mo., Dey, Yr.)
<br />./`r]r~r}j~w, MAR 4 2010
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