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STATE OF NEBRASKA
<br />96. FACILITY-NAMH (If nOt Inatltutlon, qlVe streat and n4m6ar)
<br />VA Medical Center-Grend Island
<br />8a GITY bR TOWN OF �EATN pncluda 7Jp Code)
<br />Grand Island 68803
<br />9a. RESIPENCE-STATE 96. COUNTY
<br />Nebraska Hall
<br />9d. STRE�T AND NUMBER
<br />212 East Pine 5t.
<br />'IDa. MARITAL STATUS AT 71ME OF �EATH � Marrlad ❑ Never Ma�
<br />❑ Msrdad, but separetad � W�dowed ❑ Dlvofced � llnknown
<br />71. PATHER'8-NAME (Flrst, Middle, Lsat, SufTlx)
<br />WHEN '�HIS COPY CARRIES TNE R.47SED SEAL OF THE NEBRASKA DEPARTMENT OF HEALT�i.�#1V �ERVICES, IT CERTIFIES
<br />THE BE'LpW Tp BE A TRUE COPY OF THE DRIGINAL RECORD pN FILE WITH THE NEBR,�KA D�P,q�tT�A9ElyT OF�-IEALTH AND
<br />MUMAN SERVICES, VITAL RECORDS OF�'IC�, WHICH IS THE LEGAL. DEPOSITORY FO IFA�L, RECL�RDS. ,' ., ;
<br />DATE OF ISSUANCE � e
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<br />DEPI�RTNIEIUTQF-HE,4�TH,4A(Q r'
<br />LINCOLN, NEBRA$KA �f S VICES ' '
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<br />STATE OF NEeRASKA - DEPARTMEN7 �F HEAL7H ANP MUMAN S� �IC�66, '�� F ,^' ��'
<br />RTIF TE TM �' ``
<br />1. DECEDENT'S-NAME (Firat, Mlddla, Laay Sufflx) 2. SEM ti� � 3. �A�T�,DF OFJ� o.,Dsy,Yr.)
<br />Ronald Lewis Sherman Mals � �'actohe[�,'"��'10
<br />4. CITY AND STATE OR TERRITOItY, OR FpREIGN GOUNTItY OF BIRTH 6n. Aos-Laat Birthday Sb. 11N0ER t YFJ1R 8c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., �ay, Yr.)
<br />(Yra.) MpB. �AYS HOl1RS MINS.
<br />Hastings, Nebras
<br />9, SOCW4 SECURITY NUM9ER
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<br />Ba. PI.ACE OF DEATH
<br />�pJy�� � InpaGsn!
<br />Q EWOutpatlent
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<br />February 15, 1939
<br />OTHER: � Nuroing HomaILTC � Hosplce Facillty
<br />� p�cederk'e Homs
<br />❑ OtnedSpeeiNl
<br />8d. COUNTY OF �EATH
<br />Hali
<br />a�, cirr oa rowN
<br />Alda
<br />9a. AP7. NO. 9f. ZIP CO�E 9g. INSI�E CITY LIMITS
<br />68810 � Yea Q No
<br />10b. NAME QF 8POl1SE (Flrat, Mlddle, Lset, SutFlx) If wlte, glv� maiden nama.
<br />Amy Bushhousan
<br />�2. MOTHER'8-NAME (Fint, Mmdle, Maldan SuMame)
<br />Laura Diana Bushnell _
<br />13. EVER IN U.9. AFtMEU FORCE57 Give datas at service If Yes. 7Aa. INFORMANT-NAME
<br />�vaa, No, orunk.� Yes 11/01/1956-01/2811957 Am 5herman
<br />15. METHO� OF �ISPO$171tlN 1Bs. EMBALMER-SIaNATURE
<br />p p Not Embalmed
<br />�cnmation �encombm�nt
<br />�Remwei Ornneqapedry� �6d. GEMETERY, CREMATORV OR OTHER LpCA710N
<br />Westlawn Memorial Park Crematory
<br />17a. FpNERAL HOME NAME AND MAILING A�DRE38 (Slraat, Clty or Town, 8lata)
<br />Apfel Funeral Hame, 1123 W. 2nd, Grand Island, Nebraska
<br />7Bb. LICENSE NO.
<br />CITYI70WN
<br />Grand Island
<br />CAUSE OF DEATW (See instructions and exam�
<br />. PART I. EnNI �ha cMln oI �wnb - plfellwo� Inju'NS, of Comp���bn4 Mat dlrc��y uuMd tM ONt11. P� NOT anl�f Nmlln111 CYa11U �ueh as ufdlnC 11lroat�
<br />nepirnory �rren, or venMC�ur nedll��lon w�chouc showlnp the .tlolo{ry. oo NOT AB9REVIA7E. EnMr anry a�u caua on a Ilna. Md .ddiuonal I�nu 1/ necee�ary.
<br />IMMEDIATE CAUSE:
<br />IMME�IATE CAUSE (Plnal
<br />dieeasa or condltlon resuldng a)
<br />in death►
<br />DUE TD, OR AS A GONSE UENCE OF:
<br />$aquentlally Ilst conditiDnS, If b)
<br />�ny, laading to the Causa Iistad
<br />on Ilne s. pp� 7p, O[? AS A Co UFNCE OF:
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<br />EntertheUNDERLYINGGAU3E �) r ��h �m\�_ ��
<br />(dieea6e or InJury that Initlated �
<br />tha events resultlnp In death) ouE TO, OR AS A CpNSEQUENGE OF:
<br />LAST
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<br />78. PART II.OTHER SIGNIFICANT CON�ITIONS-0ondlllona
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<br />W 20.1 EMALE:
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<br />F �Notpregnsntwlthinpaet�ysar
<br />y�,� Q Preqnant at tlma of death
<br />V Q Nat pl'apnant, 6ut pregnanl wlthln 42 day9 O} deatp
<br />� �] Not pregnanl, but pregnant 43 days to 1 year befo�e
<br />� QUnknown�f prsgnent withln the psst yaqr
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<br />!a the dritlt butllpl roaulting In H1B Undellylpg caua0 glv0n In PAR71.
<br />7Ab. RHLATIONSHIP TO DECEDEN7
<br />WIfB
<br />18c. UATE (MO., Day, Yr.)
<br />10/6/2010
<br />STATE
<br />Nebraska
<br />77b. Zlp Code
<br />68801
<br />� APPROXIMATE INTERVAL
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<br />79, WAS MEDICAL EXAMINER
<br />ORCpR ERCONTAGTE�T
<br />� YE$ NO
<br />21C. WAS AN AUTOPSY PERFpRME�7
<br />❑ YES �NP
<br />21d. WERE Al1TOPSV FIN�INGS AVAILABLE
<br />TO COMPLE7E CAUSE OF �EATH7
<br />Q YES Q NO
<br />2{a MANNER OF UEATH 27b. IF TRAN5PORTATION
<br />aturel Q Homfcldo � ❑ DdverlOperator
<br />Acc den! Q Prnd�nqlnVa6tlgatlan ❑ Paseenger
<br />� Sulcide � Cauld not ba delertnln�d � PedaaMan
<br />Q Dther ($pacify)
<br />� 24a. �ATE OF INJURV IMo., �ay, Yr.) 22b. TIME OF �NJURY
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<br />m 22d. INJU1�Ki4T WpRK7 22e. DESGRIBE HOW INJl1RV OCCl1RREd
<br />� ❑ YES U[NO .
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<br />22f. LpCATION OF INJURY - 3TREET 8. NLIMBER, APT. NO.
<br />21s, nA7E OF DEATH (Ma., nay, Yr.)
<br />22c. PLACE OF INJURY-Af home, taml, stro�t, T9C1o1'y, O}Ilca bulldi0q consuucpon sne, etc. �Speclry�
<br />CITYlTOWN
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<br />�' � 296. �ATE SIGNED (Mo., Uay, Yr.) Y3a TIME OF AEATH
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<br />� a O 23d. To tha 6�at of my knowledga, death occurred a! !ha tima, date and place
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<br />o� d due to the cause(a) stated. (Slgnature and Tltle)
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<br />25. oID 70BACC0 US CON7itIBUTE TO THE �EATH7 28a. HAS PR6AN OR
<br />�❑ YES ❑ NO PROBABLY Q UNKNOWN ❑ YES
<br />27. NAME, TI7LE AN� A DRE33 OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, C
<br />i \ . � . ro �- � � w. r. ,. A r�n_ 1 • ,. � n _ _�_ .r
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<br />2Ba. REGISTRAR'S SIGNATURE
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<br />37ATE ZIP COOE
<br />z 24a. OATE SIGNEO (Mo., �sy, Yr.) 2A6. TIME OF PEATH
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<br />O 24c. PRONOUNCE� �E4D (Mo., Day, Yr.) Y4d. TIME PRONOUNCED DEA�
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<br />� W Z I4s. On tha bae�s at exsmination andlo� Invaatlgation, In my opinlan death occurred
<br />O Q o at tha tlma, date and pl+co and due to the causa(a) atated. (Signatura and 71t1e�
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<br />UE DQNATION BEEN CON$I�ERED7 286. WAS CtlNSENT GRANTED7
<br />ryp Not AppIICAble If 29a la NO ❑ YE$ ❑ NO
<br />RONER'S PHYSICIAN OR COUNTY ATTORNEY) (TypB Or PAnt)
<br />1_anl f1 .�,hnnC�� �>(��� �-,f hhl� �ll� nR�C2�Q�
<br />�Bb. OATE FILEA BY REGIS7RAR (Mo., Dsy, Yr.)
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