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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH Alup�ffJ1� �ERVICES, IT CERTIFIE5
<br />TME L�LOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE W77'H 7HE NEBRASK.6t`1D�P��1l�F�1�1� (�F� HEA��H AND
<br />�h UMAN SERVICES, V7TAL RECORDS OFFICE, WHICH IS THE LEGAL OEPQSITpRY FOR 1l.IYL�L ��'C�RD .' �' ,;, Z� �
<br />w �; .•.�� w L J�
<br />DATE OF ISSUANCE �� �.".
<br />ST141��?' : �00�� `, t; � i ,
<br />OCT 1 9 Z009 ./ a�s��.�nr ��E���sr�,� ;;
<br />2 O 1� O O U�� D�P�R�J�E hI�EAL AIVD �
<br />LINCOLN, NFBR.4SKA HUMA11l'$t�,�lf �: � _
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<br />STATE OF NEBRA3KA- �EPAR7MENT OF HEALTH AND NUMAN SERVICES FINANG� AND S�IRPOId� �• ,.
<br />CERTIFICATE QF DEATH �� '���'��
<br />1. DECEDENT'S-NAME (FII'e�, Middlp, LBe�, 5�IIIx) 2. SEX 3.OATEDFDEATH (MO.,Diy,Yr.)
<br />Samuel Lero StoJ.l Male O�tober 8, 2009
<br />� 4. CI7Y AND B7A7E OR TERRITORY, Op FOpEI(iN COUNTRY OF BIRTH 5a. AQE-Leat Blrthday 56. UNDER t YEAR 5c. UNDER 1 �AY 8. DA7E OF BIRTH (Mo., �ey, Yr.)
<br />� (Yra.) MOS. �AVS HOURB MIN&.
<br />Grand Island, Nebraska 73 ebruary 2Q, 1936
<br />7. SOCIAL SECURITV NUMBER
<br />507-36-3349
<br />Bb. FACILITV-NAME (If not inetltutlon, piva etreet and number)
<br />Harailton Manor Nursing Home
<br />Bc. CITY OR TOwN OF DEATH Qnclude Tip Code)
<br />Aurora, 68818
<br />9a. pE31�ENCE•STATE 9p. COUNTY
<br />N Hall
<br />Bd.STREETAN�NUMBER �
<br />3424 Graham Ave.
<br />1oa. MApITAL STATl1S AT TIME OF DEATH �[ Merrled �l Never Marrled
<br />0 Marrled, but aeparated ❑ Widowed 0 �ivorced O llnknown
<br />PLACE OF DEATH
<br />h�j5PITAL: ❑ Inpetlent Q'j�$ � Nuraing Home/LTC 0 Hospice Facllity
<br />❑ ER/Outpatlen� � �8cedenPsHqma
<br />a �, o o�ne�is
<br />Bd. COUNTV OF OEATH
<br />Hami].ton
<br />Bc. CITV OH TOWN
<br />Grand Island
<br />ee. APT. NO 9f. ZIP CODE
<br />68803
<br />Ob. NAME OF $POUSE (F118�, Middle, Last, Suiflx) If wlle, glve meldan name.
<br />Marlyce Driewer
<br />71. FA7HER'S•NAME (Firat, Middle, Leat, Suffix) 12. MOTHER'$-NAME (F�ret, Middle,
<br />_ Clifford L. 5to11 Dorthea A.
<br />13. EVER IN U.3. ARMED FORCE57 Give detes of service if yee. 14a. INFORMAN7-NAME
<br />(Yes,no,orunk.) No M rlyce stoii
<br />75. METHOD OF DI5POSITION 18a. EMBAL ER-SIGNATURE
<br />�[Bufiel ��onallon �t
<br />OCremetlon DEntombment �Bd.CEMETERY, EMATpRYpROTHE OCATION
<br />❑ RamoVal p Other (Specify)
<br />� Grand Island Cemetery,
<br />17a. FUNERAL HOME NAME AN� MAILING ADDFE55 (Sfreet, City orTOwn, 5tale)
<br />18b. LICEN5E N0.
<br />I �.�( C1
<br />C�TYlTOWN
<br />Grand Island, iVE
<br />Apfel Funeral Home, 1123 West Second, Grand Island, NE.
<br />9g. INSID6 CITY LIMIT&
<br />Xl ves ❑ No
<br />Meitlen 8urnpme)
<br />McMillan
<br />74b. RELATIONSHIP TO bECED�NT
<br />Wife
<br />18c. DAT6 (Mo., Oay, Yr, )
<br />October 12, 20p9
<br />STATE
<br />77b. Zlp Coda
<br />688Q1
<br />1B. PAR7I, Enler Ihe Cp9lq,pj.PygpJg•-diaeases, InJudes, or compllcatlona•dnat tlirectly caused the death. DO NOT eNer terminal avente such es cerdiec arreet, � APPROXIMATE
<br />i
<br />ra6pl�etory erre6t, of vBntricular ti6rlllatlon wlihoul6howing Ihe etiology. �O NOT qBBREVIATE. Enter only one cau6e on a Ilna. AAd etldltionel linea if necea9ary. i
<br />IMMEDIATE CAIJSE: � onaet to death
<br />IMMEDIA7[ CAl1SE (Finol (a) D� � f j(� r, �.� � G lS�{,r
<br />dheaeewcondklonrewPong pUE TD, OR AS A CONSEOUENCE OF: I Ons6tto dea�h
<br />In daath)
<br />BequentkNy Iln candlHana, ll
<br />enY, kadlnp to the cauar tland
<br />on lin� �.
<br />Frner the 11N0ERLY1N0 CAUBE
<br />(dlesaee or In�ury that Mitleted
<br />ihe aveMs ra�ulling In death)
<br />1A6�
<br />i onaettodeath
<br />�
<br />79. WA3 MEDICAI. EXAMINER
<br />OR CORONEfi CtlNTACTEp4
<br />❑ YES �10
<br />21c. WAS AN Al1TOP3Y PERFORMED7
<br />CI VES �0
<br />Not pregnant, bul pregnent wdhm 42 days o1 death ❑ 6uicida 0 Could nol be determinad 21d. WERE AUTOP3Y FIN�INpS AVAILABLE TO
<br />C] Nol ra nan6 but re nant 43 da s Po 1 ear belore deeth ❑ D�her (BpecHy)
<br />P 9 p 9 Y Y COMPLETECAUSEOF�EATH7
<br />���UnknownNpnqnaniwitninthspeNyenY � -�� • -�� �- � � Cl YES O NO
<br />B ,. -
<br />22a. bATE OF INJURY (MG., Dey, Yr.) 226. 71ME OF INJURY 22c. PLACE OF INJURY-At homa, farm, slreat, fectory, office building, conatructian slte, etc. (Spacify)
<br />m
<br />22d.INJURYATWORK9 22e,�E5CRIB8HOWINJl1RY0CCURRE� ���
<br />(6)
<br />�11E TO.OR A8 q CONSEOUENCE OF:
<br />(c)
<br />❑UE T0, OR AS A CONSE�l1ENCE OF�
<br />i
<br />i
<br />� .. .. - �
<br />i oneel to deeth
<br />i
<br />I
<br />18. PART II.OTHER 316NIFICAN CONDITIONS-Conditions conlributlnp �o Ihe daeth 6ut nat resultinp In the underlying cause glven In PAqT I.
<br />��t/LK�NSun��.$ 7 �i��
<br />20.IFFEMALE: 21a.MANNEROFDEATH 216.IFTRAN5POR7ATIONID
<br />❑ Not pregnant within paal year �tural [] Homlclde � D�IvadOperator
<br />❑ pregnant e� Ilme al dealh ❑ AccidantU Pending Inveetlpellon 0 P�enpei
<br />p ❑ PBdestrten
<br />f,�] YE5 ❑ NO
<br />22L IOCATION OP MJUpV • STREEf & NUMBER, APT. N0. W CITYlfOWN � STR1E 21P CqDE
<br />23e. DA7E OF oEATH IMo., Day, Yr.) Q � 24a. �A7E 51QNED (MO., Pay, Vr.) 246.TIME OF oEATH
<br />S's �G - 8'^p 1 �� z m
<br />23b.DATESIGNED(Ma�,oay,Y) 23c,TIMEOF�EATH � � 24c.PFONOUNCEDDEAD(Mo.,Day,Yr.) 24d.TIMEPRONOUNCEb�EA�
<br />�d � /v' 5��0 � m 4 a � _,.._
<br />8�° q " � m
<br />,� 23d. To the 6est of my knowledge, death occurrad et the tima, date end plece fy 24e. On the 6asis of axaminatlon and/or inveatigatian, In my opinlon dealh occurred et
<br />�� end due to the Be�B� BfO�e . Ian01010 d Tilla )♦ � X� �he tlme, date Ynd plece and due to the CaueB�e) BtalBd. (Signetura and Tltle I•
<br />r /i \ � A aE r�
<br />�..J �� 8 L
<br />25.OI�TOBACCOU&ECONTRI9l1TETOTME�EATH7 28 a.HA 30 RGANOflTI55llE00NATIONBEENCON5IDERE09 26b.WA5CON$ENTGRANTED7
<br />❑ YES �olp, p pROBABLY O UNKNOWN �] YES NO Not Appllce6le if 26a is NO [] VE5�1N0
<br />- - � --�-�..........
<br />27. NAME, TITLE AND AbURESS OF CERTIFIER (PHYSICIAN, COHpNEii'3 PHYSICIAN OR COUN aTTORNEY) (Type or Pr�nq
<br />David Colan M.D. '129 North Custer Ave., Grand Island, NE 68803
<br />28s. FEGI9TRAR'S SIpNANHE 28b. DATE FILED 8Y REGIS7RAR (Mo., De , Yr.
<br />�.,.. � . r /_' _ �cr x: � �aas
<br />HHS-61 11/03 (55061)
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