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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND MUMq(V SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA ~DEPgRTN/~Ah`QF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAk•R~CC,~RIJ~ ~: "
<br />/Fi ~ w ~ .aitbL' l~ . .. '
<br />DATE OF ISSUANCE /.dC~ !fi,.). ~ ~'!F7~
<br />06!18/2010 ~ O i O O 5 C~ 4 3 A'SS73TA ~ R~1~TR~ :'
<br />V DEPPiRTM~1i~tt1"I-IANCL >,'
<br />LINCOLN, NEBRASKA HWM1#IV.SEi2~'7IC~5
<br />STATE OF NEBRASKA • DEPARTMENT OF WEALTH AND HUMAN SERVICES W;~~~ , i ~ ~+, t ~ •h;, as>~ ' ~ ~ ~~ sss
<br />CERTIFICATE OF DEATH ~~~' ~:'•••• •°' . ,: ~• ~a
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX TE OF R~ATH (Mo., Day, Yr.)
<br /> Charlotte Y'Ola Eddy Female Jwne 12', 2010
<br /> A. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. PAT!: OF BIRTH (Mo., Pay, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINE.
<br /> Shelton, Nebraska 85 March 22, 1925
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 5Q5-44-3354 H ITAL ®Inpatlant OTHER ^ Nurelrp HomalLTC ^ Hospice Facility
<br /> 8b. FACILITY•NAME (ff npt Institution, give street and number) ^ ER/Outpatlem ^ Decedent's Home
<br />
<br />~
<br />U ......,...Trim
<br />Saint Francis Medical Center
<br />^ DoA ^ other (specify)
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<br />K 8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />a Grand Island 68803 Hall
<br /> 8a. RESIDENCESTATE 9b. COUNTY 8c. CITY OR TOWN
<br />w
<br />z Nebraska Hall Grand Island
<br />~ ad. STREET AND NUMBER 6. APT. NO. 1ff. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 5419 W. Old Potash H 68803 ^ Yes ®No
<br />
<br /> 1qa. MARITAL STATUS AT TIME OF DEATH ®Married ©Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, glue maiden name
<br />!i= ^ Married, but separated ^ Widowed ©Dhrorced ^ unknown Dale R Eddy
<br />
<br /> 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br />~ Marion F Dobbs Alma Coy Musser
<br />$
<br />E 7S. EVER IN U.S. ARMED FORCE89 Give dates of service ff Y65. 14A. INFORMgNT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />~ (Yes, No, or Unlt.) No Dale R Edo Husband
<br /> 75. METHOD OF DISPOSITION 16a. EMBALMER•SIGNATURE 18b. LICENSE NO. 18c. DATE (MO., Day, Yr.)
<br />H ®Burlal ^ Donation
<br />Chris McCoy
<br />1191
<br />June 16
<br />2010
<br /> ,
<br /> ^ Cremation ^ Entombment
<br /> 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY (TOWN STATE
<br /> ^ Rempval ^ Other (Specify)
<br /> Rosedale Cemetery Rosedale Nebraska
<br /> 17a. FUNERAL NOME NAME AND MAILING ADDRESS (Street Clty or Town, State) 17b. Zip Coda
<br /> Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br /> ee instructions an exam es
<br /> ia. PAR? 1. Enbr the chain q},4wms•-0iseaaei, Inlurlei, or oompllwtloni~thit directly w4wd the death. DO NOT edter termldal eveme such ae CalrlliC amet, APPROXIMATE INTERVAL
<br /> rosplratory amst, or ventdcular abr111atlon wkhout showing the etiology. DO NOT Aa6REVIATE. tinter onry ono wow on a Ime. Add addklonal ilnae If newaeary.
<br /> IMMEDU\TE CAUSE: ~ Onset t0 death
<br /> IMMEDIATE CAUSE {Final a) gsplratltan Pneumonia. __ ; 1 Week
<br /> dlwaae or cendltlon roaultinq
<br /> In death) DUE TO, OR A5 A CONSEQUENCE OF: onset to death
<br /> aequsntlalty fist conditions, IT b) Dementia ;Years
<br /> any, Nadinq to the muse listed
<br /> on una a. DUE TO, OR AS A CONSEQUENCE OF: ;onset td death
<br /> Eller the UNDERLYING CAUSE C)
<br /> (disease pr InJury that Initiated
<br /> the events roaultinq In death) DUE TO, DR AS A CONSEQUENCE OF: 7 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 1. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> ^ YES ®NO
<br />~
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<br />u. 2D. IF FEMALE: 21a. MANNER OF DEATW 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br /> ^ Not prognam wlthln peat year ®Naturol ^ Homicide ^ DrhredOperotor
<br /> ~ YES ® NO
<br />~ ©Prognant at time of death ^ Accident ^ Pending Inveatigatlon ^ Paasangar
<br /> ^ Not prognanl, but pregnant wlthln 4Z days of death gulclde Could not bs determined
<br />© ^ ^ padeatdan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br /> ^ Not prognam, nut prognant 47 days to 1 year before death ^ Other (8peclfy) TO COMPLETE CAUSE OF DEATH?
<br /> ^ Unknown If pregnant wlthln the past year ^ YES © NO
<br />°' 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 />
<br />~r 22d. INJURY AT WORKT 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />~
<br />[] YES ^ NO
<br /> 22f. LOCATION OF INJURY -STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br /> ,_. DATE OF DEATH (Mo., Day, Yr.).~_.~_ r. r,__
<br />_ -~°^-_.-._
<br />, 24a. DATE SIGNED (Mo., bay, Yc)
<br />_~
<br />- _ 246. TIME OF DEATH
<br /> ~ W June 12, 2010 ~ ~ .
<br />__ _
<br /> ~ 2sb. DATE SIGNED (MO., Day, Yr.)
<br />~
<br />~ 2sc. TIME DF DEATH ~ ~ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> -
<br />' June 16, 2010
<br />V 07:52 PM r
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<br /> ~ 3d. TD the Wrt Of my knowledge, death oCCUrrod at the time, date and plow ~ ~
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<br /> and due to the wow{aJ elated. (Slgnaturo and TttIe) ~
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<br />and dw to the w
<br />uw{a) rtated. (Sig afore
<br />nd Tttle
<br /> Travis S. Hageman, MD g s
<br /> 2s. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28d. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 286. WAS CONSENT GRANTED?
<br /> ^ YES ®NO ^ PROBABLY ^ UNKNOWN ^ YES ®NO Not Applicable If 28a Is ND ^ YES ^ NO
<br /> L AND ADD F ERTIFIE ( I IAN, HY 1 IAN I ype Or r ht
<br /> Travis 5. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE Zeb. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> June 17, 2010
<br />
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