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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY.~t
<br />
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<br />~ ~1~"IiI~N 3>~Rt/IGES, IT CERTIFIES
<br />4~4~E ,41~T~1~~1~~ ~IF, HEALTH AND
<br />L'li'~~DRDS'(~, ?
<br />~.
<br />DATE OF ISSUANCE ~~~yr•---- ,~'~ ". fir,
<br />09/15/2010 z o i o 0 7 i 5 ~ ~; ~T'~1NL RER : ,,, ,~
<br />;. `~IS~~ r.,~.~GIST~,9R
<br />P.ARTMEIWT;OF HEALT.Ff /I, ND
<br />LINCOLN, NEBRASKA rep/ W~1,~7Aly~SERVICES ~, ,•' e`,; ~ .
<br />STATE QF NEBRASKA -DEPARTMENT OF WEALTW AND HUMAN `~~~ ~~ ~ ~. `~~ ~' '",\~'~ ~` ^~., ~ ~ Q 02567
<br />CERTIFICATE OF DEATH ~, _ ~" .,,,;",','~ ~~,"~ .~:'
<br /> 7. DECEDENT'S•NAME (Pint, Middle, Last, Suffix) 2. SEX ~ "-
<br />~ 9. D ~'iiF DEATW (Mo., Day, Yr.)
<br /> Geor a Ra mond Dunham Male
<br />`' °``September 10, 2010
<br /> 4. CITY AND 37ATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY e. DATE pF BIRTH (Mp., Day, Yr.)
<br /> (Yra.l MOS. DAYS HOURS MINE.
<br /> Kirksville, Missouri 75 August 14, 1935
<br /> 7" SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 508-38-0151 HO PRAL ®Inpatlent OTHER ^ Nursing Home/LTC ^ Hospice Facility
<br /> eb. FACILI7Y•NAME (If not Institution, glue street and number) ^ ER/Outpatlent ^ Decedem's Home
<br />K
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<br />v Saint Francis Medical Center ^ poA ^ otner(speclty)
<br />W
<br />K 8c. CITY OR TOWN OF DEATH (Include Zip Code) ed. COUNTY pF DEA7H
<br />o Grand Island 68803 Hall
<br /> 9a. RESIDENCE•STATE 96. COUNTY 9c. CITY OR TOWN
<br />z Nebraska Hall Grand Island
<br />7 8d. STREET AND NUMBER e. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY LIMITS
<br />~ 2211 Nashville St. 68803 ®res ^ No
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<br /> 10a. MARITAL, STATUS AT TIME OF DEATH ®Manled ^ Never Marrlad 10b. NAME OF SPOUSE (First, Mlddle, last, Suffix) K wife, glue maiden name
<br />!E ^ Married, but separated ©Wldowed ^ Divorced ^ Unknown Loretta Jean 8osselman
<br /> 11. FATHER'S•NAME (First, Mlddle, Last, Suffix) 12. MOTHER'S-NAME (First, Mlddle, Malden Surname)
<br />~ Floyd Dunham Gertie Powell
<br />"a- 19. EVER IN U.S. ARMED FORCES? Glve dates of service K Yea. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (res, No, or unk.) Yes D4/12l1957-D4l11l1961 Loretta Jean Dunham Wife
<br /> 15. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />H ®eurlal ^ Donation
<br />Daniel D Naranjo
<br />1071
<br />September 13, 2010
<br /> ^ Cremation ^ Entombment
<br /> 78d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> ^ Removal ^ Other (Specify)
<br /> Westlawn Memorial Park Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRES8 (Street, CIty or Town, State) 176. Zlp Cpde
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> ee ns ruc ons and exam les
<br /> 1a. PART I. Enter the chpln of events-dlaaaaas, Injurlaa, or compllcationathat tllroCtly cauwd the death. DO N07 amer terminal Buena such ai cardiac amat, ;APPROXIMATE INTERVAL
<br /> roaplrotory arran, Or WMHCUIer gbrllldtlOn wllhont ahowlnq the etiology. DO NOT ABBREVIATE. EataY Only Ona caufa on a Ilea. Atld additl0nal Iinei If neceiiary.
<br /> IMMEDIATE CAUSE: pnaet tp death
<br /> IMMEDIATE CAD5E (Final a) Amyotrpphic Lateral Sclerosis ;One Year
<br /> dlieaie or CondIt100 roaehlnq
<br /> In death) pUE TO, OR AS A GONSEQUENCE OF: onset to death
<br /> Saquenfl011y Ilat cOndlflOna, IT b)
<br /> any, leading le [he Cauca Ilatad
<br /> on nne a. DUE Tp, OR AS A CONSEQUENCE OF: onset tp death
<br /> Enter the UNDERLYING CAUSE C)
<br /> (dlaeaw or InJury that In6latetl
<br /> the ewtdi reaumnp In death) pUE TO, OR AS A CONSEQUENCE OF: 7 Onset t0 death
<br /> LAST d)
<br /> 18. PART IL OTHER SIGNIFICANT CONDITION5•Condltions contributing to the death but not resulting In the underlying cause given in PART I. 18. WAS MEDICAL EXAMINER
<br /> Dementia pR CORONER GONTAGTED7
<br /> ^ YES ®NO
<br />tY
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<br />tL D. IF FEMALE: 21a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFpRMEp7
<br />a ^ Not pregnant within pant year ®Naturol ^ Homicide ~ OriverrOperetor ^ YES ®NO
<br />W Pregnant at time of death
<br />^
<br />©pCCldinl ^ Psndlnp Investlga<lOn ^ Paaianger
<br />C,1 © Not prepnaM, but pregnant within 42 days Of death Suicide Could not ba determined
<br />^ ^ ^ Padaatrlan 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br /> ^ NOt propnant, but prognan143 days to 7 year before tleatb ^ Other (Speciry)
<br />~' ©Unknown if pregnant within the past year ^ YES ^ NO
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<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22p. PLACE pF INJURY•At home, farm, street, factory, office building, construction site, etc. (Specify)
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<br />a 2Yd. INJURY A7 WpRK7 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
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<br />^ YES ^ NO
<br /> 22f. LOCATION OF INJURY • STREET S NUMBER, APT.Np. CITYITOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (MO., Day, Yr.)
<br />2010
<br />tember 10
<br />~ W Se ~ 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
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<br /> 236. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED pFJ1p
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<br /> „ = Se tember 13, 2010 03:44 AM ~
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<br />3d. TO the beat 01 my knowledge, death eCCUrred at the lima, data and place
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<br />W 34a. On the twala Of examinatl0n and/or Invenigatlen, in my opinion death occurred at
<br />~
<br /> and tlue to the Cdule(e) Ilatad. ISipnature and Title)
<br />v ~ ~ p the time, date and place and due fo the Cauae(a) elated. (Slgnafuro and Tpla)
<br />o O
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<br /> Travis S. Hageman, MD $ o
<br /> 25. DID Tp8ACC0 USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN GONSIDERED7 286. WAS CONSENT GRANTED?
<br /> ^ YES ®NO ^ PROBABLY ^ UNKNOWN ^ YES ®NO Not Applicable If 26a Is Np ^ YES ^ NO
<br /> 2 A L N A ype or riot
<br /> Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mp„ Day, Yr.)
<br /> September 14, 2010
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