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STATE OF NEBRASKA
<br />-`' VDHEN THIS COPY CARRIES THE RAISED SEAi OF THE NEBR,4SKA DEPARTMENT OF HEALTH e 4AlD l IUIN�Yl1`� 54�RVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASIC�i DER�AJ2 T Qh ¢IEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR I�IT,�C i�EGQ ;��
<br />�.� 1+ ' d
<br />DATEOFISSUANCE � `� �a7��'�f�
<br />STAA��.� Q�PER � + � :4,�'
<br />02/10/2011 2�,i i� 2 2�� A�S�T.�a�V ��iTE��GIS?1�1�"� �"
<br />D�'l��TM���OFliE,�IL�'MA1�Q'� ,�'
<br />LINCOLN, NE8R,4SKA H(�"1�1A�I, S�ICL�S` r . �, �� •,'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AMD HUMAN SERVf�E3��;�� •�. � i3 l��`� '' ��,'� '�
<br />, . , r ,�' 41. 00376
<br />CERTIFICATE OF DEATH � �'`� ' ` f ,' "� , ; .r �� ,
<br />7. DECEDENT'S•NAME (First, Middle, Last, Sutfix) 2. SEX ` y 3.,DA'rE k:�A (Mo., Day, Yr.)
<br />Richard Duncan Stalker Male � F�tuuary 4, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTFI 5a. AGE • last BlRhday b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(YB.) MOS. DAYS HOURS MINS.
<br />Boone Coun , Nebraska 80 February 13, 1930
<br />7. SOCIAL SECURITY NUMBER Sa. PLACE OF DEATH
<br />508-24-0701 HOgpRAI � inpatient OTHER ❑ Nursinp Home/lTC � Hospice Facllity
<br />Bb. FACILITY-NAME (It rrot Institution, gNs strest and number) � ER/OutpatleM ❑ Decedent's Home
<br />�
<br />� Saint Francis Medical Center ❑ ooa ❑ otr�er �specity)
<br />c�
<br />� 8c. CITY OR TOWN OF DEATM pnclude Zip Code) Sd. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 9a. RESIDENCESTATE 8b. COUNTY 8e. C1TY OR TOWN
<br />w Nebraska Hall Grand Island
<br />LL 9d. STREET AND NUMBER . APT. NO. 9f. ZIP CODE 8g. INSIDE GTY LIMITS
<br />�, 4305 Saddle Horse CT 68803 � ves ❑ No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH Nlarrbd
<br />� � � Nevs� Martl�d 70b. NAN� OF SPOUSE (Fint, Middle, Las4 Suffix) If wife, qive maklen nam�
<br />.� ❑ Narriea, wn separa�ea ❑ wiaow•d ❑ DNorted ❑ Unknown �olene Rae Melchert
<br />m
<br />� 11. FATHER'3-NAME (First, Middle, last, Suf/Ix) 12. MOTHER'S•NAME (First, Middle, Malden S�xname)
<br />� Duncan Stalker Ann Hayes
<br />£ 13. EVER IN U.3. ARMED FORCES? GNe dates W�vice N Yes. 14a. INFORAAANT•NAME 14b. RELATIONSFNP TO DECEDENT
<br />� �ves, No, or unk.► Yes 01/04/1953-11/06/1953 Jolene Rae Stalker Wife
<br />,g 15. AAETHOD OF DISPOSITION 16a. EMBALMER�SIGNATURE 18b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />� ❑ eunai ❑ oonaaon Not Embalmed February 4, 2011
<br />� Cremation Q Entombmant �gd. CEIYIETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Rsmoval ❑ omsr �sPeciry� Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. PUNERAL HOME NAME AND MAII.IN(i ADDRESS (Street, City or Town, State) 17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />ee nstruct ons a exam a
<br />7b. PART 1. EMar th� chaln oi �w� �tli�epsss, In)uMS, Or complkatlonMhat dlr�ctty uus�d�ths dath. DO NOT Mtsr brminal �wnq sucl� u cutliac arrost, � ; qppRpXIMATE INTERVAL
<br />nsptretory arrist, w veMrlcular dbAllaGoo witho�k �howinQ 6ro �tlolopy. DO NOT ABBREVIATE. EMar onry one cause on a Nne. Add addkional Ihres if nacessary. .
<br />IMMEDIATE CAU$E: ; oncet W death
<br />. IMMEDIATE CAUSE (flnal e) Pneumonia � � � � ; Couple of Days
<br />disssse or condkion ntnklny . �
<br />M d°° �� DUE TO, OR I13 A CONSEQUENCE OF: ; onsst to death
<br />s.a�,.�n��y w.� �o�amo�., �r b) Squamous Cell Carcinoma ; Years
<br />any, Ieadlny to the cauw Iisqd � . � �
<br />on une a. p�E TO, OR AS A CONSEQUENCE OF: 7 onset to death
<br />EnNrth� UNDERLYWO CAUEE c) Diabetes Type 2 .. . � � ; Years
<br />�dlaaasa or i�yury that InitlaUd. � .
<br />9
<br />ths evsMS resWtinp M�ath) pVE TO, OR A3 A CONSEQUENCE OF: � � � � o�st to death
<br />LAST � d � . . .
<br />78. PART II.OTHER SIGNIFICANT CONDITIONS�CondiGons coMributlnp to the daath but notrwulting In the underlying cause Qiven in PART 1. 19. WAS MEDICAI EXAMINER
<br />OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />� . IF FEMALE: 21a. MANNER OF DEATN 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />f- � No! propnmt wkhin part ywr � NaturN � Homicide � Driwr/Op�rator
<br />� � PrepnaM at tims ot death � p,oddeM � Pendinp ImeMlpaNOn . ❑��np�r ❑ YE8 � NO
<br />� Not prepnaM, but prepnant wRhin 4Y days of death � WdesMm 21d. WERE AUTOPSY FINDIN(i3 AVAILABL
<br />� � NM pnyn�nt, but pnynant 4E day� to 1 yex Wfore death ❑$ulcitla � CoulA not t» dstermtned ❑ a � f�s�c�y, TO COMPLETE CAUSE OF DEATH?
<br />� � unknown H prepnant wuh�n ths past year ❑ YES ❑ NO
<br />� 22a. DATE OF INJURY (MO., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, sVeet, hctory, office buliding, corotructbn site, etc. (Spsclfy)
<br />� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F�
<br />� YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo:, Day, Yr.) 24b. TIME OF DEATH
<br />3� � February 4, 2011 � � � � g
<br />�} 2Sb. DATE SIGNED (Mo., Day, Yr.) 2SC. TIME OF DE0.TH � k� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� � o Februa 4, 2011 06:58 AM �<�
<br />�
<br />9tl. To tM bea of my knowledye,�deat� oaumd at th� time, tlab antl plaa � pM. On tba basb o( wminatlon aod/or inwrtipation, In my opinlon dnth occumA rt
<br />$ a r M Ow to t M cau s e �s) stah 0. ( S i q nrtun and TkN) a tM tim�, date md plaa and dw to tM cau�s) apqd. (81pnaWn antl TNN)
<br />~ Kenneth Vettei, MD . ~ � ;
<br />. D TOBAC USE C TRIBUTE TO THE D H7 2ta. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREDI 28b. WAS CONSENT GRANTED't ''
<br />Q YES � NO � PROBABLY � UNKNOWN � YES NO Not Applkabie M 26a Is NO YES �] NO
<br />. , L ype or M
<br />Kenneth Vettel, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (MO., Dey, Yr.)
<br />February 8, 2011
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