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u � . STATE OF NEBRASKA �,
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF H�'A�.�'l-T A'111b7 t�J(�+IAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE N�BR,4�.A„�f�P,AR�T �T QF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY�'O,jt�U�4�.� ��'C���"���;� .
<br />� �� % �
<br />DATE OF ISSUANCE � �� . � �'�� ;�
<br />11/29/2010 � 01 i 0 3 4 3 5 � ,���� S COOPER ;: ; �,:
<br />� �'A�SI��t�L7' Sr�'AT�' REqI'��"�qR ' = , ' .
<br />�a �
<br />LINCOLIV, NEBRASKA ' ��E;4MA,�f�SERVIG`�,��' r � �
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN��SEiZ�GICfi� �� �� i��� 4 } �, y ��
<br />CERTIFICATE OF DEATH r,, ' �s'� �'-• • � � -.�- , � ` 10 03394
<br />, G,�
<br />1. DECEDENTS•NAME (First, Middle, Last, SuHbc) 2. S�X r 4 . ° - ; 1 :.DATE-OF DEATH (Mo. Day; Yr.)
<br />ward Nelson Roe Male ' d ' �'�.November�9
<br />4. CITY AND 3TATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(YB.I IIAOS. DAYS HOURS MINS.
<br />Canton, South Dakota 90 August 8,�;1920i
<br />7. SOCIAL SECURITY NUMBER 8a. pLACE OF DEATH
<br />503-26-2917 OH SPRAI. � Inpatlent O_ THER � Nuraing Home/LTC � Hosplee Facttity
<br />8b. FACILITY•NAME pf rrot Irretitution, glve street and number)
<br />� ❑ EWOutpatlent ❑ DecedenYs Home
<br />� Westem Hall County Good Samaritan Center ❑ ooa ❑ Other(SpeeHy)
<br />� Sc. CITY OR TOWN OF DEATH pnclude Zip Code) Bd. COUNTY OF DEATH
<br />o Vliood River 68883 Hall
<br />� 9a. hESIDENCESTATE 8b. COUNTY 9a CITY OR TOWN
<br />z Nebraska Hall Grand Island
<br />LL 9d. TREET AND NUMBER e. APT. NO. 9f. ZIP CODE 8g. INSIDE CITY LINATS
<br />� 404 Woqdland Drive 68801 � res ❑ No
<br />. 10a: MARITAL STATUS AT TIME OF DEATH � AAar►ted ❑ Never MaMed 10b. NAME OF SPOUSE (First, Mlddle, Last, SuRix) ITwlfe, give maiden tmme
<br />� �y] N�rrled, but separated ❑ Wldowed ❑ Divorced ❑ Unknown M8f�8�@ Greguson
<br />m
<br />� 11. FATHERS-NAME (Firat, Mlddie, Last, SuHlx) 12. MOTHER'S-NAME (First, Middle, Maiden Surr�ame)
<br />m /#rthur G Roe Palma Monrad
<br />a 13. �VER IN US. ARMED FORCES? GWe dates oT sarvice H Yea. 14a. INFORMANT•NAME 14b. RELATIONSMP TO DECEDENT
<br />E
<br />� �Yes, roo, or Untc.) Yes 01/22/1946-12/10/1957 Tim Roe San
<br />,$ 15. METHOD OF DISPOSfftON 16a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />� � Burial ❑ DonaUon
<br />Tracey Dietz 1328 November 24, 2010
<br />G] Cremadon � EntombmeM �gd. CEMETERY, CREMATORY OR OTHER LOCATION CITY i TOWN STATE
<br />Q Removai ❑ Other (Specffy)
<br />Grand Island City Cemetery Grand Island Nebraska
<br />178. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Sfafe) 17b. Zip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />IB. PART 1. EMer the chatn ot eveMe-dlaeases, InJuriea, or compllWtlone•fhat dlrecUy pused the death. DO NOT enter terminal eveirte euch as cardlac art�t, �
<br />'Yespirarory arrest, or ve�iwlar flbrillatlon wffhout showl� t6e eUOtogy. DO NOT ABBREVIATE EMer onty o�re cause on a Iiire. Adtl additlonal Ilnea H neceaeary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (F7nal e) Pneumonia
<br />dlsease or condMlon rasulting
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />saquentla�ty nar com�ona, B b)
<br />anY� leading to the cauae Ilaletl
<br />on I�� a DUE TO, OR AS A CONSEQUENCE OF:
<br />�ce. er� uNOew.nmc cnuse �)
<br />(disaase.orinJurythatlnittated
<br />the ave�Aa reaulttng in death) DUE TQ OR A$ A CONSEQUENCE OF:
<br />� d)
<br />APPROXIMATEINTERVAL
<br />onset to death
<br />Days
<br />o�et to death
<br />o�et to
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS�Corrclttio� co�rtribuU� to the death but not resulting In the underlying cause gWen In PART i. 18. WAS MEDICAL EXAMINER
<br />Metastatic Prostate Carcinoma, Atrial Fibrillatlon, Dementla, Anemia Of Chronic Disease OR CoRONER CoNTaCTED�
<br />� ❑ ves � No
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED9
<br />� � NotpregnaMwithlnpas[y�r � Natural � Homiclde � DHverlOpersWr
<br />� � Pregnant et Hme of death � q�deirt � Pending InvesdgaHOn ❑ Peasen88r ❑�S � NO
<br />a � Not pregnaN, but pregnant withln 42 daya ot death � s„idaa � cowa no� be demrmi�rea � Pedeau�a" 21d. WERE AUTOPSY FINDWGS AVAILABLI
<br />'° � NM pregnent, but piegnarrt 49 tlays to i year before deaqt � p�� (g���y� TO COMPLETE CAUSE OF DEATH?
<br />� � Unimown H P�eB�aM wfthln the Pest Yaer . . ❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (Mo„ Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, faetory, offlce building, eonshuctlon alte, etc. (Specffy)
<br />�
<br />.� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />� ❑ ves ❑ No
<br />22t. LOCATION OF WJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo.� Day, Yr.� - - - --- 4a. QA7E SI�NEQ {Mo.� Day, Ya) -- --. 24b. TIeeEQE DEATH y-----
<br />� �, November 19, 2010 �:� � -
<br />� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH �� k r 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />��,, Z Navember 23, 2010 05:23 PM g� Z
<br />$ O 3d. To the beat of my Imowietl9e� death oaurt�i at tne tlrtre, date and pWCe g � 24e. On tha basie M exeminatlon anNor Inveati
<br />�� end due to tlre cause(s) atatetl. �SI nature end Tkie ,$ 8 a tlon, in m y o pinlon tleath occurred at
<br />��, 8 1 0 �� the tlme, date and place and due to fhe cauae(s) statetl. (SiBnature end Tide)
<br />Jay C. Anderson, MD '" ;
<br />YES ❑ NO ❑ PROBABLY � UNKNOWN � ❑ YES � NO
<br />7E, ITLE D S3 OF CER FIER S Z�UW, 1 T T, ORONER'S P.
<br />� C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />NotAppilcable H26a Is NO f I YES I I NO
<br />ReGiSrRqR'S 51GNATURE� �� 1� _� 286. DATE FlLED BY REGIS7
<br />��L�,. �10�
<br />, r . flr November 24, 2010
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