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STATE OF NEBRASKA
<br />WH,EN THIS COPY CARRIES TME RAISED SEAL pF Th1E NEBRASKA D�PARTMENT OF HEAl �INQ�MU�d.4IV 56RV3�L�5, IT C�RTIFTES
<br />THE BELpW 1"O BE A TRUE COPY OF THE ORIGINAL RECORD ON FZLE WITH THE NEBR45,K,��E'p,ARrM��T, OP� a-IEALTH ANb
<br />HUMAN SERVICES, VITAL RECORpS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR^V�.�54L• � . F �CQ ��
<br />, . �� +��
<br />DATE pF ISSUANCE ,W �� ��, `,+
<br />�
<br />, 2�02�2009 2 0�. 0 0 8 9 5 S sT �� 4 �'� �?�������aR '-
<br />ASSI�TA
<br />DEPr'�RTNI�'M7",�`'1"+!�:�t�' ,'
<br />LINCOLN, NE'BRASKA HL�I�AN •S�2 IG�S ;�- - �s
<br />5TATE OF N88RASKA - pEPAR7MEN7 OF HEALTH AND HUMAN SERVICES ��„ �'� ���' �' � ��` �'�°
<br />r_��rr���r_er� n� nFe-ru �, ,' ��' .' 09 02747
<br />1. pECEOENT'S-NAME (First, Middle, Last, Suffix) R. SEX ' 3. AATE_OF f1EATH �Mo., Day, Yr.)
<br />Elvin Ra Denman Male November 23, 2009
<br />4. CITY AND STATE OR TERRITORY, pR FQREIGN COUNTRY OF 91RTH 5a. AGE - laet BlRhday b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DA7E OF 81RTH (Mo., Ody, Yr.)
<br />(Yrs.) MOS. DAYS HpURS MIN3.
<br />Doniphan, Nebraska 84 August 22, 1925
<br />7. SOCIAL 5ECURITY NUMBER ea. PLAGE pF DEATH
<br />5p8-30-$574 HOSPITAL Q Inpatlent (�7HER � Nuning Home/LTC � HpSpICe FaCllity
<br />8b. FACILITY-NAME (If not Institutlon, plve street and number) � ER/Outpatlent ❑ UecedenYa Home
<br />� Wedgewood Care Center ❑ DOA ❑ Other (Speclfy)
<br />� Sc. CITY pR TOWN OF 6EA7N jlnclude Zip Eode) __- _ _. _ 8d. COtlNFY-f7F pEk'Fi+ ._.. _.-
<br />o Grand Island 68803 Hall
<br />� 9a. RESIDENCESTA7� 9b. C04NTY 9c. CITY OR TOWN
<br />z Nebraska Nall Grand Island
<br />� 8d. STREET AND NlIMBER 9e. APT. NO. 9f. ZIP CODE 9g. IN$IDE CITY LIMITS
<br />�, 6125 5outh U.S. Hi hwa 281 68801 � YE$ ❑ No
<br />a t0a. MARITAL STATUS AT TIME pF DEATH � Marrled ❑ NeveY Married 70b. NAME OF SPOUSE (Flrst, Middle, Last, Suffix) If wlfe, give malden name
<br />� ❑ Marrlad, but separatad ❑ Widowed ❑ Dlvorced [] Unknown Carline Clausen
<br />m
<br />� 11. FATHER'5-NAME (First, Middle, Last, Suffix) 72. MpTMER'5�NAME (First, Middle, Maidan Surname)
<br />a Clifford Denman Pearl Kingston
<br />°' 13. EVER IN U.S. ARMED FORCES9 Glve dates of servlce If Yas. 14a. INFORMANT-NAME 74p. R�4ATIONSHIP TO OECEDENT
<br />E
<br />$ �ves, No, or unk.) Yes 03/29/1944-05l21/19A6 Carline Denman Wife
<br />$' 15. METHO� OF DISPOSITION 18a, EM6ALMER SIGNATURE 766. LICENSE Np. 18C. DATE (MO., Day, Yr.)
<br />� � Burlal Q Qonation �
<br />Chris McCoy 1191 November 28, 2009
<br />❑ Crematlon ❑ Entombmant 16d. CEMETERY, CREMATQRY OR QTHER 40CATION CITY / TOWN STATE
<br />0 Removal [f Other (5pecify)
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City oY Town, State) 17b. Zip Code
<br />Livingston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 68803
<br />H ee instructions an exam es
<br />18. PART I. Enter tha chaln of avents--di6eaee6, injuYle6, or CompllCatlOn�dhAt diroctly cauaed tha daath. DO NOT anter term�npl Bvente auCh a6 CaMiaC arrest, ; APPROXIMATE INTERVAL
<br />roaplratory arrest, or vantdcular Obdllatlon witnout ahow�ng lne ati0lopy. UO NOT A88REVIATE. Entar only one cauaa on a I�ne. Add adtllGOnal Iinas H neCetsery.
<br />IMMEDIATE CAUSE: ; onset to death
<br />IMMEDIATE CAUSE (Flnal a) Multiple Myeloma ; Months
<br />�dlaeaae or condlelon roauleing ��
<br />in death� DUE TO, OR AS A CONSEQUENGE pF: ; onset to death
<br />Saquantially liaf condklona, R b)
<br />any, Ieadiny ta tha cause Ilsted
<br />on Iine a.
<br />DUE Tp, OR AS A CONSEOUENCE OF: ; onset to death
<br />Entgr the UNOERLYING CAU5@ C �
<br />(Alwpea or InJury thaf Inttlatrd
<br />tna evantt retultlnq in doath) pUE Tq, OR AS A CON3EpUENCE OF: : onset to death
<br />usT d)
<br />18. PART II.O7HER SIGNIFICANT C4NDITIpNS�Candltions contributing to the death but not resulting In the undarlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTEp�
<br />� � YES �] NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 27c. WAS AN AUTpPSY PERFORME�?
<br />41.
<br />� � Not pregnant wlthln past year � NatuYel � Homiclda � urlveNOperator Q YES � NO
<br />U � Preqnant at tlmB of death � pccident � pand�ng Invasdgation Q paaeBnpaY
<br />T � Not p�egnant, bPt pregnant wlthin 4x Aays Of death � Petlattdan 27d. W�RE AUTOPSY FINDINGS AVAILABLE
<br />a � Sulclde � Could not ba tlatormmod TO COMPLETE CAUSE OF DEATH7
<br />� � Not preqnant, but prBgnanl d3 daye to 1 yeaY dato�e dBath � Othar (Specify)
<br />v ❑ YES Q NO
<br />� � Unknown I{ prapnant witltin tlta paat yaar
<br />a 22a. DA7E OF INJURY (Mo., Day, Yr.) 22q. TIM6 OF INJURY 22c. PLACE OF INJIIRY•At home, Tarm, straet, factory, off�ce bu�ldinp, constructlon slte, etc. (SpeclTy)
<br />E
<br />�
<br />a 22d. INJURY AT WORK? 22a. DESCRIBE HOW INJURY OCCURR�D
<br />0
<br />~ ❑ YES � NO
<br />2N. 4QCATION OF INJURY - STREET & NUMBER, APT.NO. CITYITpWN STATE ZIP CODE
<br />� 2Sp. bATE OF prHTli (Mo., Day, Yr.) � � � � �� �� � � � � � � 4a.�DATE SI�NED (Mo., Day, Yr.) � 24b. TIME OF OEA7N
<br />�' W November 23, 2D09 „� 333
<br />��} 23b. DA7E SIGNED (MO., Day, Yr.) 23C. TIME OF PEATH ��� J 24c. PRONOUNCED DEAD (Ma., Day, Yr.) 24d. TIME PRONOUNCEA PEAp
<br />�� Navember 24, 2009 03:25 PM
<br />� '� $
<br />� 9tl. TO the be�t oT my knowladqr, death vccurrvd at the tlmr, datr and placs ���
<br />antl dua to tne causa s tated. 5i ture and 7it1e) $'� z4e. On the pa61e of examinatlan and/or Invartlqatian, In my opinlon death puumd at
<br />a e 1 1 6 1 e�a o 25 p Iho tlmr, data and placs antl dw to tha cauaa�a) eta»d. (8lpnsluro pnd Tilfs) ��
<br />~� Travis S. H�geman, Mp ~ s o
<br />25. DID TOBACGO USE CONTRI9l1TE TO THE DEATH� 26a. HAS ORGAN OR TISSUE DONATIpN 9EEN CONSIDERED9 26b. WAS CONSENT GRANTED7
<br />❑ YES ❑ NO ❑ PR08AeLY � 11NKNOWN 0 YES � NO Not Appllca6la Ii 28a Is NO ❑ YES ❑ NO
<br />. AM , ITL N D E R N ypa oY Y nt
<br />7ravis 5. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNAIURE � 28b. DATE FILED 8Y REGISTRAR (MO., DBy, YY.)
<br />December 1, 2009
<br />Exhibit "A"
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