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STATE OF NEBRASKA
<br />� WHEN THIS COPY CARRIES THE RAISED SEAL QF THE NEBRASKA HEALTH AND HUMAN SERM/CES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECO�Qd FILE�WITi�
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS�$.S�1�i311t,�lEkllCtt�
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. -
<br />DATE OF ISSUANCE � �,
<br />MAR 15 20�5 9 � = - ��«r-�. cc��R � .
<br />-- - � .
<br />LINCOLN, NEBRASKA ^' O�"` O ' ���'" H�A aA1D HUMAN SE�I€ES
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPOAT'
<br />CERTIFICATE OF DEATH g
<br />i. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE Of DEATH (Mo., Day,Yr.)
<br />Wa ne Eu ene Ma Male March 8, 2005
<br />4. CITY AND STATE OR TERRITORY, OR�FOREIGN COUNTRY OF BIRTH 5a. AGE-Last 8irthday Sb. UNDER 1 YEAR 5c. UNDER t DAY 6. DATE OF BIHTH (Mo., Day, Vr.)
<br />Pierce County, Nebraska (Vrs.) 7f MOS. DAYS HouRS MIN3. M$y 14, 1928
<br />7. SOCIAL SECURITY NUMBER � Ba. PLACE OF DEATH .
<br />SO� � HOSPITAL: Olnpatient QILiEB: ONursingHOme/LTC ❑HospiceFacifity
<br />8b. FACILITY-NAME (If not instftution, give streel and number) � ER/Oatpatlent ❑ DecedeqfsHome
<br />St . Francis Medical Center ❑ oa+ ❑ ome�
<br />Bc. CITY OR TOWN OF DEATH (Include Zlp Code) Bd. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />9e. RESIDENCE•STATE 9b. COUNTY 9c. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />9d.STREETANDNUMBER 9e.�APT.NO 9f.ZIPCODE
<br />2530 N. Webb Rd 68803
<br />10a. MAfiITAL STATUS AT TIME OF DEATH �) Married � Never Marrted 706. NAME OF SPOUSE (First, Middle, Last, Sufffx) if wite, give maiden name.
<br />❑Married,butseparated ❑Widowed ❑Dlvorced dUnknown I Ardith C. Morton
<br />11. FATHER'S-NAME (First, Middie, � Last, � Suffix)
<br />Arthur May
<br />13. EVER IN�U.S. ARMED FORCES7 Glve dates of service if yes. 14a. INFORMANT-NAME
<br />(Yes ,no,orunk.)YeS :6-15-51/5-1-52 Az'dith C. Z
<br />15. METHOD OF DISPOSITION 16a. MER-SIGNATURE �
<br />C�Burial ❑ Donatfon � � -(,0�,�
<br />❑ Cremetlon ❑ Entombmenl 18d. CEMETEpY, CREMATORY O7HER LOCATION
<br />❑ ❑
<br />12. MOTHER'S•NAME (First,
<br />Millie
<br />16b, LICENSE N0.
<br />1092
<br />CITY I TOWN
<br />9g. INSIDE CITY IIMITS
<br />�I YES ❑ NO
<br />Middle, Maiden Surneme)
<br />Youngs
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16c. DATE (Mo., Day, Yr. )
<br />March 11, 2005
<br />STATE
<br />Removal Other(Specity) 3826 W. Stol�ley Park Rd � Grand Isalnd, Nebraska 68803
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City orTown, State) 17b. Zip Code
<br />Curran Funeral Chapel 3005 South Locust St. Grand Island, Nebraska 68801
<br />18. PART I. Enter the chain of events--d)seases, injwies, orcomplications•-that directiy ceused ihe death. DO NOT enler terminal events such es cardiac errest,
<br />respiratory arrest, or ven�ricular fibrlliation withoul showing the etiology. DO NOT ABBREVIATE. Enter oniy one cause on e Iine. Add additional Ilnes if necessary.
<br />IMMEDIATE CAUSE: �
<br />IMMEDIATECAUSE(Flnal (a) CT�i^ i� � O �V L� � � N �\`- _` � �T�� � \
<br />dlaeaseorcaMftionreau111ng DUETO,ORASACONSE�UENCEOF. � ,
<br />indeath) . �.
<br />SequeMially Iist conditlons, if @) �S �-� � � < �� t"� �-� O � � � �� Z
<br />arry,leadingtothecausellated DUETO,ORASACONSEQUENCEOF: �
<br />on line a.
<br />EMertheUNDERLYINGCAUSE ,
<br />(dlseaseorinJurylhatiNttated (°�
<br />theeve�tsresultingindeath) DUETO,ORASACONSEQUENCEOF:
<br />IASf
<br />(�
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS-Contlilfons contribuling lo the dealh but not resulting in the underlying cause giveri in PART I.
<br />20. IF FEMALE:
<br />❑ No[ pregnanl within past year
<br />❑ Pregnant at tlme of death
<br />❑ Not pregnant, bul pregnant within 42 days of deeth
<br />❑ Nol pregnant, but pregnant 43 days to t year before death
<br />❑ Unknown If pregnant wilhin the past year
<br />21e.MANNEROFDEATH 21b.IFTRANSPORTATION
<br />� NaWrel ❑ Homkide ❑ DrivedOperetor
<br />❑ Accident0 Pending Investigation � Passenger
<br />❑Pd tl
<br />' APPROXIMATEINTERVAL
<br />I
<br />I
<br />� onset to death
<br />I
<br />� K� � tJ J\'� S
<br />I anset io death
<br />I
<br />' ����.S
<br />�
<br />i onset to deeth
<br />I
<br />. i onset to death
<br />I
<br />I
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONEA CON7ACTED9
<br />❑ YES � NO
<br />21c. WAS AN AUTOPSY PERFORMED7
<br />❑ YES �I NO
<br />e esran p�d.WEREAUTOPSYFINDINGSAVAILABLETO
<br />�❑ Suicide ❑ Could not be determined
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY
<br />� m
<br />22d.INJURYATWORK7 22e.DESCRIBEHOWINJURYOCCURRED
<br />Q YES ❑ NO �. � �
<br />❑Other(Specify) �pMPLETECAUSEOFDEATH7
<br />_ ❑ YES ❑ NO
<br />22c. PLACE OF INJURKAt home, farm, sireet, factory, olfice building, construcllon slte, etc. (Specify)
<br />22f. LOCATION OF INJURY-57REET & NUMBER, AP7 N0. CfTY/fOWN' STATE - . ZIP CODE
<br />23a. DATE OF DEATH (MO., Day, Yr.) Z 24a. DA7E SIGNED (Mo., Dey, Yr.) 24b.TiME OF DEATH
<br />aQ '� '_ Q "_` 4� . a U Z m
<br />� U N ¢
<br />� 23b. DATE i SIGNED (Mo., Day, Yr.� ��^ 23c.TIMEOF D�EA �_� 24c. PRONOUNCED DEAD (Mo., Day,Yr.) 24d. TIMEPRONOUNCED DEAD
<br />Eai V3"Q ^ OJ ��J m E� m
<br />'�' 9� 23d. To the best ol my knowledge, death occurred at the time, date and plece �_�� 24e. On Ihe basis o( examinetion and/or investigation, in my opinion death occurred et
<br />g m ue to the cause s) stated. Signature and Title ♦ � p p the time, date and place and due to the cause(s) staied. (Signature end Tille )♦
<br />� ` �U
<br />~a .�� V. ZnC\�'. � IV�� ~ c�°
<br />25.DIDTOBACCO USE CONTRIBUTETOTHE DEATH7 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED7 26b. WAS CONSENT GRANTED?
<br />❑ YES NO � PROBABLY ❑ UNKNOWN ❑ YES �O Not Applicable it 26a is NO ❑ YES NO
<br />27. NAME, TITLE A D ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />John J. Cannella M.D. 729 N. Custer AV Grand Island, Nebraska 68803
<br />I 28a. REGISTRAR'S SIGNATURE f 28b. DATF FILED BV REGISTRAR (Mo., Day, Yr.)
<br />� �1 • �IAR 1 1 2�0�
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