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� � S'TATE OF.NEBRASKA
<br />WHEN THIS COPY CARRIES THE R.4ISED SEAL OF THE NEBRASKA DEPARTMEN,T DF HEALT y �►� rrt ���rtF
<br />THE BELOW Tp BE A TRUE COPY OF 1"HE ORXGINAL RECORD ON FILE WITH TME NEI�RA�'iA� � �. •
<br />HUMAN SFRVICES, VITAL RECORDS OFFICE, WNICH IS THE LEGAL DEPpSTTORY�Q�.,�I ;''��''� �"�, . f k�, '""`°`''
<br />. .. �*J c`r � >. �,���P t e��a .
<br />DATE �F ISSUAIVCE A , �"� �„ � _ ��} � �
<br />���I��d��Y1q�� .�'ti � F:! '� �i �
<br />�Z�ov2o�o 2 4110 U 4 4 3 �, � ''� `� �'''�': �'
<br />-A � r�
<br />a� ; �� ' a, '��
<br />LINCOLN, NEBfiASKA M � T � � �� 4 �' ;^, '
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<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SER�E� ��' � i�'�` `��" ''
<br />AAltiT�r�A�T!^^ �.� ..�.�., r ��"r ... . .. . 1Q 03452
<br />a.�R � �r��.r►� � �rr v�r1� n . �, �.,. ,. .
<br />1. pECEDENT'S•NAME (FIY�t, Mlddle, Lasy Sufflx) Y. SEX ,. •,_ 3. UA7E OF DE47F1(Mo., Day, Yr.)
<br />Jfmmia Gerald Nelson Male -° - �fovember 27, 2010
<br />4. CITY AND 8TATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Laat Birthday b. UNDER 1 YEAR 6c. UNDER 1 DqY 8. oqTE OF BIRTH (Mo., Day, Yc)
<br />(Y�.) Mq$. DAYS HOUR5 MINS.
<br />Loup County, Nebraska 74 ,lanua 31, 1936
<br />7. SQCIAI SECURITY NUMBER 8a. PLACE OF DEA7H
<br />5Q6-50-6554 �❑ �npatient OTHER ❑ Nuning Nome/LTC � Wosplca Faclllty
<br />8b� FACIIITY-NAME (H not Instkutlon, giva street and numbaY) � ERlOutpatfent � Detedent's Homa
<br />C
<br />DOA Other (Specify)
<br />� 1819 South Ingalls St. CI ❑
<br />W Bc. CfTY OR TOWN OF GEAT}4(k�cku�e �Ip Cade) - ._ _ __. : � ffd. COUNTY OF CR'ATH -_ _
<br />�
<br />3 Grand Island 88803 Hall
<br />.� . RitIDEN �7pTE 9b. COUNTY !c. GfTY OR TOWN -.--
<br />w Nebraska Hall Grand Island
<br />LL 9d. STREET ANp NUMeER e. APT. NQ. 8f. Z{p CODE 9p. IN$IDE CI7Y LIMITS
<br />� 1818 South In alls St. 68803 � res ❑ No
<br />� 9oa. MARI7AL STA7t7S AT TIME OF DEATN � Martled ❑ Nevsr Mar►kd 706. NqME OF $POUSE (Flr�f, Mlddla, l.asR 5uf(Ix) IT wN0. ghro maldan name
<br />� ❑ Marriad, but saparated ❑ W�dowad ❑ Drvorced �] unknown Jane D DeVer
<br />� 11. FATNER'$-NAME (Flrat, Mlddle, �ast, $ufflx) 12. MOTNER'S•NAME (First, Mlddlp, Malden Surnamp)
<br />John Emmett Nelsqn Rosa Agnes Schlafer
<br />� 13. EVER IN U.8. ARMED pORCE37 Glva datas oT sarvlCe I/ Ya�. 74e. INiORMANT-NAME 14d. RELATIONBHIP TO DECEDEFIT
<br />�vaa, No, or Unk.) Y63 11/02/1954-12/31/1976 Jane D Nelson Wife
<br />� 16. M@TNOD OF �ISPqSIT10N 18a. EMBALMERSIGNATUR� 18b• LICEN$� NO, 16c. DqTE (Mo., Day, YrJ
<br />� � suna� ❑ ponatlon Derek Apfel 1240 December 1, 2010
<br />❑ Cramatlan ❑ EntomdmeM �gd. GEMETERY, CREMATORY OR CTFIER LQCATION CITY 170WN $TqTE
<br />❑ Rqmoval [] Othar (SpaCify)
<br />Fort McPherson National Cemetery Maxwell Nebraska
<br />17a. FUN�RAL HOME NAl1AE AND MAILIN6 ADDRESS (Streeq Clty or Town, State) 17b. 21p Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebrask� 68801
<br />ea ns ruct ons an ex�m les
<br />16. PART 1. EMsrttw cna�q o} avanta-.disa�ws, InJuM�, ar compllptlonsdhat alrocty cauwd tM AWh. p0 NOT �nbr qrminsl rwmf such a� wrdlac artan, ; ApPROXIMATE INTERVAL
<br />re�plratory arrvrt, o� vemrlcula� Ilbnurtlan wMnaut ahowlnp tM stlolopy. DO NOT ABBREVIATE. EMsr onty ona caup on a I��w. Add �ddRlanal nms It n�caasary.
<br />IMMEDIATE CAUSE: ; onset to death
<br />IMMEOIATECAUSE(FInAI B�CArCI12CA1'rIl�F1(11Ia ; I�Tlmed'18te
<br />dlwaN Or co�dRlon re�uRlnq�
<br />in de»n> DLIE TO, OR AS A CONSEQUENCE OF: ; onaet tn death
<br />asquenuany nat condk�ons, N b)
<br />any, baAinp to the CAU�s Ilstad
<br />on IMr p. DUE TQ, OR AS A CONSEQUENCE OF; ; unsat to death
<br />W�Irr 1ns UNt�E1uvIHG WwBE G ) .
<br />� �� (dlMan or InJury tbq dnlfl�tM �
<br />ths svant� resuklnp in death) DLIE TO� OR AS A CONSEQUENCE OF: � OneAt tb da0th
<br />� dl
<br />78. PART II.OTHER SIGNIFIGANT CONpITION$�Conditlona contrlbutlnq tv the daath but npt resuBing In tha undarlylnp cauae pivan In PART L 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />� � YES [] NO
<br />� 0. IF FEMALE: 21a. MANNER OF pEATH 21b. IF TRANSPORTATtON INJUR 21c. WAS AN AUTOPSY PERFORMED7
<br />�
<br />� � NptpropnanlwhhM paatyaar � Natunl Q Homldda � DrIwNOprntor � YE8 � NO
<br />� � Pry9�AM otll�M Of dwth � AcGMllt � Psndinp inwnipaaon � Paaqnpir
<br />� Q Nol pnpnanR dut pwpnant w11tAn a7 dayr a( dsath � P�de�tAan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />(� Su�cw� � Could nw M dnaminsd TO COMPLETB CAUSE OF bEATH?
<br />� Not pnpnant, bUt propnaM 43 Aiys to 1 yiar M/ore aiath � Other (Sprcly)
<br />� [] YE$ Q NO
<br />d � U�known 1( prpnrnt whhln tna paq yarr
<br />� 22p, pATE OF INJURY (Mo., Day, Yr.� 22b. TIME OF INJURY 12c. PLACE OF INJURY•At homo, farm, sVaef, factory, ottica bulldin�, cvmtructian slte, etc. (Spaclfy)
<br />E
<br />$
<br />a�i 22d. INJURY AT WORK7 22e• pE3CR18E IiOW INJURY OCCURRED
<br />F
<br />� YES Q NO
<br />22f. I.00ATION OF INJURY - STREET & NUMBER, APT.NO. CITY/rOWN $TATE ZIP CO�E
<br />29a. DATE OF �EATN (Mo., DaY. Yr.► � ° --- 3!�Al'B�7.� !r►J " Yd11. 71ME OF DEATH
<br />� W N ��� . November 29, 2010 Approx. U8:0a PM
<br />��� ssb. DA7E SIGNEn (MO., Day, YrJ 23c. TIM� OF DEATH ��� 24c. PRQNOUNCED DEAD (MO., Day, Yr.) 24d. TIME PRONOWNCEq pEAD
<br />$ �� �`� Novem ber 2 7 2 0 1 0 0 8: 3 5 P M
<br />7d. 7e tln batl of my knowlydps, tlwth occwnd at !Ir qm�, aap and pWq $ p�,�, pn q» yw1� of �w�Mn�tlon andlor 1nwWprtion, M my opfnlon MNh occumd at
<br />$� ind dlw l0 t1N CiiuM{f� qated. (5lpnaturo mG TIlle) E� tM ryms, dAH and plPq ind due to tM auM�s) O�tsd. (S�pnature and Tltla) .
<br />~� " �� Lynelle Homalka, Hall peputy County Attorney
<br />25. Dlp TOBACCO USE CONTRIBUTE TO THE DEA7H� ZBa. HA$ pR(iAN OR TISSUE DONAT�ON BEEN CON81b�RED? 29b. WAS CONSHNT GRAN7E�7
<br />� YES ❑ NO [] PROBABI.Y � UNKNOWN ❑ YE8 � NO Net Applicabk N 28a Is NQ [] YES ❑ Np
<br />, , pe or rin
<br />Lynelle Homolka, Hall Deputy Counry Attorney, 231 S. Locust, P.O. Box 387, Grand Island, Nebraska, 68802
<br />x8a. REGISTRAR'S SIGNATURE 286, pATE FILED BY REGISTRAR (MO., Day, Yr.)
<br />November 30, 2010
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