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� �' STATE OF NEBRASKA ���:�
<br />.
<br />' WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL7H,,.�l��C�I�IAIV :SF�RVIC�'S IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBkA�K:4 ��M• '�M�IU�.QI� �-1�ALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FpR. �IT�,L "f E�ql�f1�5 �
<br />� . '>��.� t' 3 v� � � A' ��
<br />DATE OF ISSUANCE 4 �
<br />�, �� ��,., .
<br />� � oa.io4izo� � � O 110 3 4 3 4 ,�.����� ��o�En �-�� �b�, ��, �� ���
<br />a�s�t�urrr �r,a���€��rz�� ; „� �
<br />1��',PA�'Tl�l�'NT t?Fa ANf.� "` "
<br />�� LINCOLN, NEBRASKA , ' � M .�i�' , • + V�� q � � 'µ
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<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERHfC��S ;n �� �° � r ft�°�:Y� 01073
<br />CERTIFICATE OF �DEATH � � ' �� „ , :,� . ti =�
<br />1. DECEDENTS-NAME (Flrat, Mlddie, Last, SufBx) 2 SDC j 1'�, 3. DpTE'OF �EA'1'H (Mo., Day, Yr.)
<br />William R Mills Male ``Ma�eh 28, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Blrthday b. UN�ER 1 YEAR 5c. UNDER 1 DAY e. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y►s•) MOS. DAYS HOURS MINS.
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<br />30CIAL SECURITY NUMBER
<br />523-40-0374
<br />�, FACILITY-NAME (If not 6reUtutlon, gHe straet;
<br />Nebraska Heart Hospital
<br />.j CITY OR TOWN OF DEATH pnctude Zip Code)
<br />Uncoln 68526
<br />74 Septembe
<br />8a. PLACE OF DEATH
<br />HOSPRAL, � InpaUent O E❑ Nuraing HomeILTC
<br />❑ ER/OutpaUent ❑ Decedeirt's Home
<br />❑ DOA ❑ Other (Spacify)
<br />6d. COtiHTY OF DEATH -' - �.
<br />Lancaster
<br />1936
<br />� Hospice Facllity
<br />�aJ RESIDENGE-STATE eb. COUNTY 8C. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />dJ STREET AND NUMBER 8e. APT. NO. 8f. ZIP CODE 9g. INSIDE CITY LIMRS
<br />4145 Springview Drive 68803 � res ❑ No
<br />08. MARITAL 3TATUS AT TIME OF DEATH � Mazriad ❑ Never M1flarried 1ob. NAME OF SPOUSE (Firat, Mlddie, Last, Sufl7x) IT wHe, gWe maiden rpme
<br />❑ nnaMOa but separatad ❑ vmaowea ❑ Divorced ❑ Unknown Mary Summers
<br />7. FATHER'S-NAME (First, Middle, Last, Sutthc) 12. MOTHER'S•NAME (First, Middle, Malden Sumame)
<br />Theadore A Mills Violet A Ki�kpatrick
<br />3. EVER IN U.3. ARMED FORCES? GNe dates oi service B Yes. 14a. INFORMANT-NAME 14b. RELA770NSHIP TO DECEDENT
<br />(Y�, No, or Unk.) Yes 01/06/1954 Mary Mllls Wife
<br />5. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE 16b. UCENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />❑ euna� ❑ oonaaon �ot Embalmed
<br />April 2, 2011
<br />� Crematlon ❑ EMombment �gd. CEMETERY, CREMATORY OR OTHER LOCATION CffY / TOWN STATE
<br />❑ Removal ❑ Other (Speeffy)
<br />Aspen Crematlon Service Lincoln Nebraska
<br />7a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code
<br />Aspen Aftercare Cremation & Burial Servtce, Inc., 4822 Cleveland Ave., Uncoln, Nebraska 68504
<br />18. PART 1, EMer the ahain ot everhe--0Iaeases, InJuriea, or compllcaUOnedhat dlrectly caused the tleath. DO NOT eMer terminal everrte Buch ae cardlao arteef,
<br />resplratory arrest, or verrtricular flbAlladon wkhout showing the etlotogy. DO NOT ABBREVIATE EMer only one cauae on a Ilna. Add addWonal Iinea it �recewary.
<br />IMMEDWTE CAUSE:
<br />IMd1EDIATE CAUSE (Flmdl a) q�ouic Braln Damage
<br />dfsease or wndltlon reauldn� .
<br />�� ��� DUE TO, OR AS A CONSEpUENCE OF:
<br />SequeMialty Ilst eondktons, f( b) R6Splratory.AtTest
<br />airy. Ieatling to tfie cause Itefed
<br />on pne a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enterthe UNDERLVINO CAUSE �) Status Post Severe COPD �
<br />(dlaease orinJurythatiniGated
<br />tire evente resultlng In tleath) DUE TO, OR AS A CONSEQUENCE OF:
<br />`"� d) Coronary Artery Bypass Grafting Surgery
<br />II.OTHER
<br />conMbuting to the death but not
<br />W
<br />�y, 20. IF FEMALE: 21a. MANNER OF DEATH
<br />�. � NM P�9nant widUn Peet Year � Natural � Homidde
<br />� q P�egna�rt at tlme ot death � p�q�M � Pentling Invastlgatlon
<br />a �❑ Not Pre9�eM� but ptegnant wkhin 44 tlays oT death � Suidde � Coultl rtot be delertnhred
<br />� Not pregna�rt, but pregnarrt 4S daye to 1 year befare death
<br />� � Unknown 11 pregnaM wtthin the past year
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At hi
<br />�
<br />.� 22d: INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />❑ ves p No
<br />2N. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATW (Mo., pay, Yr.) ��
<br />March 28, 2011 ,�
<br />} 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ��� Y
<br />Z March 30, 2011 05:35 PM �
<br />�� 9d. To the best M my knowled8e. tleetb occurted af tire tlme� date and place $ q � o
<br />entl tlue to the cauae(s) emted, (Signeture and Tkle) $ 4�
<br />Giles S. Hedderich, MD ~ g$
<br />a
<br />� YES U NO U PROBABLY � UNKNOWN �� YES ❑ NO
<br />E, TIT D ADDR OF RT FI R(P SIC , IC T 7', C RONEP
<br />Giles S. Hedderich, MD, 7440 S 91st St, L(ncoln, Nebraska, 68526
<br />. REGISTRAR'3 SIGNATURE r1 _ _ �. _
<br />APPROXIMATEINTERVAL
<br />onsetto death
<br />4 Days
<br />onset to death
<br />4 Days
<br />onaetto death
<br />Years
<br />o�et to death
<br />3 Weeks
<br />in the underlying cause given in PART I. 19. WAS MEDICAI. EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES � NO
<br />1b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED9
<br />� DrtveAOperator
<br />� ���� ❑ v�s p No
<br />� Pedestrian 21d. WERE AUTOPSY FlNDINGS AVAILA
<br />��� (g ��� ) TO COMPLETE CAUSE OF DEATH?
<br />❑ v�s ❑ No
<br />farm, atreet, factary, office bullding, cor�4uctton sfte, etc. (Speciry)
<br />24a.
<br />STATE
<br />DaY: Yr:J
<br />ZIP CODE
<br />24n. YINAE OF CEAi H "
<br />!Lyi��
<br />On dre baels M exeminadon anNor InveatlBaBon, ln my opinlon death ox�med et
<br />the tlme, data and p18ce and due to the cauae(e) statetl. (Slg�ature and Tttie)
<br />Not Applicable If 26a Is NO ❑ YES � NO
<br />28b. DATE FlLEp BY REGISTRAR (Mo., Day, Yr.)
<br />April 1, 2011
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