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<br /> STATE OF NEBRASKA
<br />
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN,SfRVICES, IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEP,,ARIrMENT F,,WEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL R#TpR ) ;
<br /> DATE OF ISSUANCE , , ~
<br /> DEC 0 ZOO9 STANLEYC QP~R
<br /> rG o a o 8 3 O 9 ASSI, TiA1~r ST~rF REGISTRAR
<br /> DEpA FN7 ~QF'HSA!'TH,'AND °j r , . x
<br /> LINCOLN, NEBRASKA NUM~1'~ 0,11 Nr .r1
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<br /> STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE$+
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<br /> 1.DECEDENTB-NAME (Pint, Middle, Last, Suffix) 2.8EX " (rATEq , H.(Mq;;Oay,Yr,j
<br /> Frances Ellen Allison Female Noverriber25 20,
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH So. AGE-Last Birthday Bb. UNDER 1 YEAR 6e. UNDER 1 DAY S. DATE OF BIRTH (Mo.', Day; Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINE.
<br /> Buffalo County, Nebraska 86 June 14, 1923
<br /> 7. SOCIAL SECURITY NUMBER 6a. PLACE OF DEATH
<br /> 505-28-7725 b2k&!Aj Inpatient OTHER, Nursing Home/LTC ❑ Hospice Facility
<br /> U Bb. FACILITY-NAME (If not institution, give street and number) n ER/OulpaUont Decedanl'e Home
<br /> Lakeview-A Golden Living Center DOA ❑Other(speclfy)
<br /> Sc. CITY OR TOWN OF DEATH (Include Zip Code) Ed. COUNTY OF DEATH
<br /> Grand Island 68801 Hall
<br /> 8s. RE810ENCE-STATE 9b. COUNTY 9c, CITY OR TOWN
<br /> 7
<br /> Nebraska Hall Grand Island
<br /> 9d. STREET AND NUMBER 0e, ApT. NO, 0f. ZIP CODE
<br /> 9g. -INSIDE CITY LIMITS
<br /> 2520 W. John Street 68803 ® Yes.[] No
<br /> 10a. MARITAL STATUS AT TIME OF DEATH ®Ma"fed ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last Suffix) If wife, give maiden name.
<br /> ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ unknown Robert Dean Allison
<br /> C!.
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<br /> 11, FATHER'S-NAME (First Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Sumama)
<br /> q0 Charles H Hein Emma R Herzog
<br /> IA 13. EVER IN U.S, ARMED FORCES? Give dates of service If Yes, 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br /> F
<br /> (Yea, No, or unit-) NO Robert Dean Allison Husband
<br /> 16. METHOD OF DISPOSITION 16a. E R-siGNATUR 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br /> ❑BCrul p9.t-bn r,(,,q ~e~J~• / C, '7 November 30, 2009
<br /> ®Cnmatlon ❑Bntomhm.nr
<br /> ❑Removal ❑other(ap.ely) d. CE TERY, CREMATORY OR OTHER LO ATION CITYrrOWN STATE
<br /> Central Nebraska Cremation Services Gibbon Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 176, Zip Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> CAUSE OF DEATH See Instructions and examples)
<br /> la. PART I, Enter the yLaAtpLayaBls - die.a.e., Intarles, of contpucattone- that alnctly caused the death. Do NOT enter terminal esenta such a. cardiac arrest, APPROXIMATE INTERVAL
<br /> respiratoryarrest, or whorigular Oh Filiation without showing the euolagy. DO NOT ABBREVIATE. Emar only one Cause on a line. Add additional lines N necsasery. r
<br /> I
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final 1 , r
<br /> 'disease or condition resulting a) a Ci~ytr-~ ~~r- L1~~ r~er:~~~_.>r., •
<br /> In death)
<br /> DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Sequentially list conditions, If n r
<br /> any, leading to the cause listed b) L 1 C e~~-CI(' {C I,r.C
<br /> on line a, DUE TO, OR As A CONSEQUENCE OF: onest to death
<br /> C r
<br /> Enter the UNDERLYING CAUSE c) ~ r
<br /> (disease or Injury that Initiated
<br /> the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF; , onset to death
<br /> LAST
<br /> r
<br /> d) r
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<br /> 10. PART 11, OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given in PART I. 19, WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> ❑ YES ❑ NO -
<br /> 20. IF FEMALE: 21s, MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> it (q~~ot pregnant within past year Natural Homicide
<br /> "f'r~ ~ [3 ❑ Driver/Operator ©YES NO
<br /> ❑Pngnant at time of death ❑ Accident Pending Investigation ❑ Passenger
<br /> ❑ Not pregnant but pregnant within 42 days of death ❑ Suicide ❑ Could not be determined 0 Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br /> TO COMPLETE CAUSE OF DEATH?
<br /> © Not pregnant, but pregnant 43 days to 1 year before death © other (specify) ❑ YES ❑ NO
<br /> ro
<br /> ❑Unknvwn If pregnant within the papt year
<br /> L1.
<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 /> t) nl
<br /> 22d. INJURY AT WORK? 220. DESCRIBE HOW INJURY OCCURRED
<br /> ~ Q YES 1] NO
<br /> 22f. LOCATION OF INJURY • STREET 6 NUMBER, APT. NO. CITVITOWN STATE ZIP CODE
<br /> 23a, DATE OF OF.ATH (Mo Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> .i; ~ 11 ~q t in m
<br /> J 23b. DATE SIGNED (Mo., Day, Y1.) 23c. TIME OF DEAT 24c, PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> E d9 J.3(31L?m O.<
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<br /> eui L) 23d. To th est of y knowledge, death occurred at the time, date and pace 21e. On the bade of examination and/or Investigation, in
<br /> •D and data to the cause a dale my opinion death occurred
<br /> r~. (Signatures tla) at the time, date and piste and due to the cause(s) stated. (Signature and Title)
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<br /> 26. E]YES TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. H-A~IS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br /> IJ YES JJNO PROBABLY El UNKNOWN IJ YES NO
<br /> Not Applicable If 28s Is NO DYES [1 NO
<br /> 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNT/ ATTORNEY) (Type or Print)
<br /> SA J~1 1(a~ M 0 r~J 2t 5 1Z11)WtOu S C11i X04 6'i 03 ~x
<br /> 26a. REGISTRAR'S SIGNATURE 26b. DATE FILED BY REGISTRAR (Mo., Day, Yr,)
<br /> .,alt
<br /> DE
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