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�' STATE OF NEBRASKA
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<br />' WHEN THIS COPY CARRIES THE RAISED �SEAL OF THE NEBRASKA DEPARTMENT OF HE�,��i� `,4�1F�. f� MAN 5�RVICES, IT CERTIFIES
<br />THE BELOW TD BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NL�Bh"A� 5�,. 4`�4�'P�R�R9FNT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSIATORY--FOR � AL •RE��Q„S �
<br />'� :��� � �.' a 7 � C p ��C,�
<br />DATE OF ISSU,4NCE � ° ' ° �
<br />''" ;fd • �.. n `�'
<br />05/18/2010 2 0�. �. 0 3�. � G � t -�' �7ANLEY S, CODPEk `:` �yi a;.
<br />,#� � ASS��I"A`t�7 � ,T � REr7.�`Tl�AR
<br />° e °'-ClEp��tV�T��AL.TI�I /�AID
<br />LINCOLN, NEBR,4SKA ' �"fIIJMAl1� SEf21/IC�ES�. �: �f'> ;"�
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER,VI�45� �� �,. co� ,.•� k � .. 10 01340
<br />CERTIFICATE OF DEATH r .'��;� •••:..,�.�• ;,�` �
<br />1u DECEDENT'S-NAME (First, Mlddle, Last, SuRbc) 2. �uBX, � � ��" l 3. DAiE dF DEATH (Mo., Day, Yr.)
<br />Onda Ella Scott �Female _`May 10, 2010
<br />4',; CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Laet BiRhday b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />lY►8.) MOS. DAYS HOURS MINS.
<br />Boelus, Nebraska 95 July 26, 1914
<br />7, SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />506 OS T � �npaUerR OTHER ❑ Nural� Home1LTC � Hospice Facllity
<br />8p. FACILITY-NAME (H not Inatitution, give street and number) � ER/Outpatient ❑ DecedenYs Home
<br />�
<br />� Mary Lanning Memorlal Haspltal ❑ ooa ❑ Other(Specify)
<br />� 8c. CITY OR TOWid OF DEATH pncluda 2ip Code) Bd. COUM'Y OF DEATH
<br />o Hastings 68901 Adams
<br />� 8�. RESIDENCE-STATE 8b. COUNTY 8c. CI1'Y OR TOWN
<br />w Nebraska Hall Prosser
<br />7 8tl. STREET AND NUMBER 8e. APT. NO. 9f. ZIP CODE 8g. INSIDE CIIY UMITS
<br />�' I 11968 West Platte River Road 68883 ❑�s � No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH ❑ MarHed ❑ N�ver Marrled 10b. NAME OF SPOUSE (Ftrst, Mlddle, Last, Suiflx) if wHe, BNe malden nama
<br />z ❑ Marrled, but separated � Wldowed ❑ Dlvorc�l ❑ Unknown
<br />�
<br />�1. FATHER'S-NAME (First, Middle, Last, SuNlx) 12. MOTHER'S•NAME (First, Middle, Malden Sumame)
<br />m Royal Bishop Onda Unknown
<br />°' 16. EVER IN U.S. ARMED FORCES7 Glve datea of aerWce H Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />$ �res, No, or unk.) No Joe L111ey Son
<br />,� 1S. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 76b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F � surta� ❑ oo�don Derek Apfel 1240 May 14, 2010
<br />❑ CremaUan Q EMombmeM 16d. CEMEfERY, CRENWTORY OR OTHER LOCATION CITY / TOWN STATE
<br />'' 0 Ramorai ❑ aner (speary> �uniata Cemetery Juniata Nebraska
<br />�7a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, Sffite) 17b. Z(p Code
<br />�� Apfel Funeral Home, 411 W 19th St., Box 126, Wood River, Nebraska 68883
<br />CAUSE OF DEAT See instructions and exam les
<br />1& PART L Errter 8re thain M eve�rte� �dlsaases, inJuries, or complicatlonsthat diracily eaused the death. DO NOT e�rter terminal everrte auch as cardiac ertest, ; APPROXIMATE INTERVAL
<br />reepfratory arteat, or veMNCUIar flbriilatlon without ehowing the etiolQgy. DO NOT ABBREVIATE. EMer only one cauae on a Iine. Add addltlonallinea B�ry. �
<br />IMMEDUITE CAUSE: ; or�et to death
<br />�'uwmeowre cause �fl� a) Cardiopulmonary Arrest ; 10 Min
<br />diaease or comlidon resuldng
<br />I1° �'� DUE TO, OR AS A CONSEQUENCH OF: � o�� ro d��
<br />�' Seque�rtlally qat condklone, If b) Cachexia �
<br />� eny, l�ding to the puse Ilsted :
<br />! on Ilne a DUE TO, OR AS A CONSEQUEN E OF: : ortset to death
<br />eme.u,e uwoew.nNO cnusE �) Advanced Age
<br />I (tllaease orinJurythatlntdated
<br />�rthe eveMe reauitlng In death) DUE TO, OR AS A CONSEQUEN�.E OF: : orreet t0 death
<br />'ubsr d)
<br />�,8. PART II.OTHER SIGNIFlCANT CONDIT'IONS-Condttior� coMributing to the death but not resulUng In the umleriying cause given In PART I. 79. WAS MEDICAL EXAI4NNER
<br />i Esophageal ObstrucUon OR CORONER COPIT'ACTED7
<br />� ❑ YES � NO
<br />�
<br />W;0. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21a WAS AN AUTOPSY PERFORMED?
<br />� i Q NoS pregnairt wlthin past year � NaWrel � HoMdtla � DrivedOperator � YES � No
<br />� ,. Q Pregnarrt at tlme of death � pccldeM � Pemling Investi8�on ❑ Pe�ee� �
<br />a �� Q Not pregna�rt, but pregnaM wtthln 42 days of deatA � Pedeatrlan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />� suiclde � could not be aetermDred TO COMPLETE CAUSE OF DEATHT
<br />� NM PreB� but pre8ne�rt 49 Aaya to 1 year betore death � Other (SPecltY)
<br />� ;,. � UnknownHPre9�wlthinthepastyear . ❑ YE$ ❑ NO
<br />� . DATE OF INJURY (MO., Day, Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURY•At home, ferm, atreet, factory, offlce bullding, constructlon sRe, etc. (Speciiy)
<br />t� �
<br />.S 22d. INJURY AT WORK? ?2e. DESCRIBE HOW INJURY OQCURRED
<br />F� I
<br />❑ ves ❑ No
<br />�2F. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN S7ATE ZIP CODE
<br />�
<br />23a. DATE OF DEATH (Mo., Day, Yr.) � 24a. DATE S�GNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />:� � May 10, 2010 � �
<br />� �} 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ��� 24c. PRONOUNCED DEAD (Mo„ Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� Z Ma 11, 2010 03:OQ AM � d<�
<br />� � . To the best of my knowledge, tleath oeeurted at the tlma,' and place ��� 24e, On tAe besie ot exeminadon andlor Investigadon, in my opinlon death oxurred at
<br />;� � and due t0 the ceuse(s) atatetl. (Signature and Tkie) $ �� the tlme, date and place and due to the cause(s) atated. (Signature and Tltie)
<br />"' � Richard French, MD ~ � o
<br />S. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />;', ❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applicabte H 28a is NO ❑ YES ❑ NO
<br />7. N TITL� D ADDRESS OF ERTI I P S ISTANT, C RO �R S P I COUNTY A O ype or PHnt)
<br />;' Richard French, MD, 2115 N Kansas Avenue, �Hastings, Nebraska, 68901
<br />�28a. REGISTRAR'S SIGNATURE � . 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.J
<br />�' May 14, 2010
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