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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH. ARID 11LfMAA~ ,$'ERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASIt'~f DERARTN(EIU.T"QF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIT~1L'`f2~COhD5..'" a
<br />_'~ /~
<br />DATE OF ISSUANCE ~~/~ ~~' `,
<br />08/24/201 Q 2 0 ~ u 0 ~ ~ :l 0 $~'dNL~Y S,, cOOPEA~ ..: - , ,~~
<br />As~~srAN"~;~1-are R~~Ti~ar~ ,.
<br />DEP~FFtTM T OF 1iEA`L9 ~! AN,~ .'~ -
<br />LINCOLN, NEBRASKA l-IUNIAIN. SERVICES ,, ~' '
<br />57ATE OF NEBRASKA - pEPARTMENT OF HEALTH AND HUMAN SERVICES •' •~ ~ t-i ;:;; `~~ ,. ti.. ~ p Q2342
<br />„r.. ' ;. ....
<br />CERTIFICATE OF DEATH
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Sufflx) 2. SEX ~3.'~DAT OF DE74TH (Mo., Day, Yr.)
<br /> Duane La Rue York Male ` Au'gtist 19, 2010
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY li. DATE OF BIRTH (Mo., Day, Yr.)
<br /> IYn•1 MOS. DAYS HOURS MINE.
<br /> Arapahoe, Cplorado 87 Jul 2, 1923
<br /> 7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br /> 507-18-7598 HOSPITAL ^ Inpatient OTHER ®Nuraing Homa/LTC ^ Hospice Faculty
<br /> 8b. FACILITY-NAME (if not Institution, glue street and number) ^ ER/Outpatlartt ^ Decedent's Homa
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<br />Lakeview-A Golden Living Center
<br />^ DOA ^ Other(Spaciry)
<br />~ 8c. CITY OR TOWN OF DEATH (Include Zlp Code) ed. COUNTY OF DEATH
<br />d Grand Island 68801 Hall
<br /> 9a. RESIDENCE-STATE 8b. COUNTY 9c. CITY OR TOWN
<br />w
<br />z Nebraska Hall Grand Island
<br />LL 8d. STREET ANp NUMBER e. APT. NO. 9T. ZIP CODE 8g. INSIpE CITY LIMITS
<br />~, 708 East Sunset Ave. 68801 ®YES ^ Np
<br />
<br /> 10a. MARITAL STATUS AT TIME OF pEATH ®Married ^ Never Married 10b. NAME pF $PpUSE (First, Middle; Last, Sufflx) If wife, glue maiden Hama
<br />!E
<br />m ^ Marrlad, but separated ^ Widowed ^ Divorced ^ Unknown Eileen E Moser
<br /> 11. FATHER'S-NAME (Flrsq Middle, Last, Sufflx) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br /> Roy E York Lydia Fischer
<br />~
<br />°'
<br />E 13. EVER IN U.S. ARMED FORCES? Glva dates pf service If Yes. 14a, INFpRMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ (Yea, No, or unk.) Yes 02/04/1943-01/10/1946 Eileen E York Wife
<br />~}' 15. METHOD OF pISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />F ®Burlal ^ Dpnatlon Trace
<br />Dietz 1328 August 23
<br />2010
<br /> y ,
<br /> ^ Cremation ^ Entombment
<br />
<br />^ Removal ^ Other (Speclry- 18d. CEMETERY, CREMATORY pR OTHER LOCATION CITY /TOWN STATE
<br /> Grand Island City Cemetery Grand Island 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 /> 1a. PART 1. Enter the chain o! evenL• •dlwewa, InJurlas, or cempllCetlonadhat directly uusatl the death. DO NOT enter terminal aventa such as nrdlac arrort, APPROXIMATE INTERVAL
<br /> rosplYatory arrest, or ventricular flbAllation wflhout ehowlnp the etiology. D(3 NOT ABBREVIATE. Enter onty ane wuw an a Ilne. Add additional Ilnef If necessary.
<br /> IMMEDIATE CAUSE: orlsat to death
<br /> IMMEDIATE CAUSE (Final a) RBSpiratory FallUre ; ~1 Week
<br /> dlaeaae or condition resulting
<br /> In death) DUE TO, OR AS A CONSEQUENCE OF: { pnset t0 death
<br /> Sequentially IIK condkiona, If b)
<br /> any, leading to the CeuN Meted
<br /> on Ilne a.
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE C)
<br /> (dlagaas or In)ury that Inltlated
<br /> the sventa roauldng In death) puE Tp, OR A$ A CONSEQUENCE OF: onset to death
<br /> LAST d)
<br /> 18. PART 11. OTHER SIGNIFICANT CONDITIONS•Gandltlons cordrlbuting to the death but not resulting In the underlying cause given In PART I. 19. WAS MEpICAL EXAMINER
<br /> Alzheimers Dementia OR CORONER CONTACTED?
<br /> ^YES ®NO
<br />~
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<br />LL 20. IF FEMALE: 21 a. MANNER OF DEATH 214. IF TRANSPORTATIpN INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />M ^ Nat prognant within peat year ®Natardl ^ Homicide ^ Drlwrtpperotor
<br />YES NO
<br />U ^ Pregnant al time of death ^ Accident ^ Panding Invastlpatlon ^ Paswnger
<br /> Not pregnant, but prognant within 4Z days of death Suicide Could not be determined
<br />^ ^ ^ Padeatrlan 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br /> ^ Not pregnant, but pregnant a3 days to 1 year before death ^ ether (9peClTy) TO COMPLETE CAUSE OF DEATH?
<br />a
<br />~
<br />^ Unknown If prognant within the peat year
<br />^ YE$ ^ NO
<br />
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<br />E 22a. DATE OF INJURY (Ma., Day, Yr.) 22b. TIME pF INJURY 22c. PLACt: OF INJURY-At home, farm, strast, factory, office building, construction site, etc. (Specify)
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<br />a 22d. INJURY AT WORK? 22e. DESCRIBE HpW INJURY pCCURREp
<br />d
<br />i"
<br />^YES ^ NO
<br /> 22f. LOCATION pF INJURY • STREET & NUMBER, APT,Np. CITY(rOWN STATE ZIP CODE
<br /> 23a. DATE pF DEATH (MO., Pay, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> ~ W August 19, 2010 ~
<br /> ~ ~ 23b. DATE SIGNED (Mp., pay, Yr.) 2sc. TIME OF DEATH ~ ~ ~ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> r
<br />E u ~ Au ust 20, 2010 02:58 AM r
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<br /> e~ C+ 30. To ma beat of my khowletlge, death occurred at the tune, date and place
<br />
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<br />349.On the balls of examinatlon andlor Inveatigatlon, in my opinion death occurred at
<br /> and due to the cau
<br />e(s) slated. (Signature and Title) p the lima, tlate and place and due to the cauw(a) atahd. (Signature and Title)
<br /> s Jennifer L. Brown, MD p
<br /> 2S. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN pR TISSUtF pONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br /> ^ YES ®NO ^ PROBABLY ^ UNKNOWN [] Yt53 ®NO Not Applicable H 28a Is NO ^YES [~ Np
<br /> I N ) ( ype or r
<br /> Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> August 23, 2010
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