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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH A61(��t �(%MAVV'„�i,ERI�(IGF� .IT CERTIFIES
<br />Tl-lE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASI�'D `$�M�'�1GT�OFJ�EAf.TH i4ND
<br />HUMAN SERVICES VITAL RECORDS OFFICE WHICH IS THE LEGAL DEPOSITORY FOR �7' ��t p ,' I�ECO S, �' a � p
<br />i i . � '4:� �1 d ' ` w $ ��',
<br />°�� r / r '� �
<br />DATE OF ISSUANCE ,� , � a L� ', �� ' `
<br />r � s7`��r�=� s, ,Gop�eR �;:; ;'� <
<br />02/14/2011 � � � � 0 � 1� � l AS;iI�f�INT ������s;f� �� p� .
<br />Dk`�'A�l ,ME1,11 fj�"' t7�1'A�11D "',
<br />LINCOLN, NEBRASKA l�(lI�RAk,$�'l�,�^SCES. " - ' ` ��
<br />, ,.,.
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVI�ES �a� h� ,�'�',� y � �' -y B � 4 tl� +� �_'I`� OO42B
<br />GCK I IFIGAI t Vt UCA1 FI ; P "' . .. ;y �,�<,'�a *,,
<br />1. pECEDENT3•NAME (First, Middle, Last, SuffUc) 2. SEX = F�_ 3:'UATE OR DEATH (Mo:, Day, Yr.)
<br />Grace Ima Shaffer Female Febrwary'9, 2011
<br />4. �ITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Leat Birthday b. UNDER 1 YEAR Se. UNDER 1 DAY 8. DATE OF BIRTH {Mo., Day, Yr.)
<br />n'�•) MO3. DAY3 HOURS MINS.
<br />&loux City, lowa 91 January 7, 1920
<br />7. $OCIAL SECURITY NUMBER 8d. PLACE OF DEATH
<br />479-16-5155 �� InpaUerrt OTHER ❑ Nurai� HomeILTC � Hosplce Facllity
<br />8b:, FACILITY•NAME pf not Ir�tidrtlon, gfve street and number) � ERlOutpatlent ❑ Decede�rt's Home
<br />�
<br />� lSaint Francis Medical Center ❑ D�A ❑ Other(Speclfy)
<br />v
<br />� 8c: CITY OR TOWN OF DEATH pnclude Zip CodBJ Sd. COUNT'Y OF DEATH
<br />o �rand Island 68803 Hall
<br />� 8a.; RESIDENCE-STATE 8b. COUNTY 8c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />� 8d: 9TREET AND NUMBER 8e. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY LIMITS
<br />�' 1215 South Lincoln Avenue 68801 � YES ❑ No
<br />y� 10a. MARRAL STATUS AT TIME OF DEATH Q Marrled ❑ Never Nlartied 10b. NAME OF SPOUSE (First, Middle, Last, Suff6c) N wHe, glve matdan name
<br />� p n+�►naa but saparatad p wnaowaa ❑ on�o��aa ❑ Unknown Mervin Shaffer
<br />d
<br />� 11: FATHER'3-NAME (Firet, Mlddie, Last, Suf(6c) 12. MOTHER'S-NAME (Firet, Middle, Maiden Sumame)
<br />� ,James Red Edna Lewis
<br />°' 13: EVER IN U.S. ARMED FORCE9? Give dates of aervice N Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />� Ilves, No, or unk.j No Jean Wh e Daughter
<br />� 18. METHOD OF DISPOSITION 18a. EMBALMER-SIGNATURE 186. UCENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F C] eunai ❑ DoimUon Not Embalmed February 11, 2011
<br />� Crematlon Q EMom6me�rt 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 TOWN STATE
<br />p Removal ❑ Other (SpeclTy) �ntral Nebraska CremaUon Servlces Gibbon Nebraska
<br />178. FUNERAL HOME NAME AND MAILING ADDRESS (Street, CHy or Town, State) 1Tb. Zip Code
<br />Apfel Funeral Hame, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See instructions and exam les
<br />18.'PART 1. Enter tha chain ot eve�rta-�dlaeases, �nJuHes, or complicedona-that directly caueed tire death. DO NOT wrter terminal aveMS euch as cardlac arresR : APPROXIMATE INTERVAL
<br />resplraMry artest, or venMcular flbrllladon wffhout ehowing the etlology. DO NOT ABBREVIATE. EMer only orre ceu� on e tl�re. Add additlonal ii� R neeassery.
<br />IMMEDIATE CAUSE: ; o�et W death
<br />IMMEDIATE CAUSE (Flnal a) Colitis Nonspeciflc,with dehydratlon,acute Renal Failure � Days
<br />di�ease or conditlon resuHing -- . _ -. - - - -
<br />In death) DUE TO, OR AS A CONSEGUENCE OF: : onset to death
<br />sequeMia�ly �iat cond�da�re, tt b)
<br />�
<br />eiry, Ieading ta the cause Iisted
<br />od nne a DUE TQ OR AS A CONSEQUENCE OF: � orreet to death
<br />�ncer me uNOEw.nNO cnuse c}
<br />ew
<br />(Ulseaea ot Injury that Initlat8tl
<br />the eveMe rawriting In ueath� DUE TO, OR AS A CONSEQUENCE OF: : ortset to death
<br />usT d)
<br />16. PART II.OTHER SIGNIFlCANT CONDITIONS-0ondftlons coMrlbuting to the death but not resuldng In the underlying cause given In PART I. 18. WAS MEDICAI. EXAMINER
<br />Recent Heart Attack;pneumonia;progressive DemenUa; severe Osteoporosis OR CORONER CONTACTED9
<br />� ❑ ves � No
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />� � NM pregnaMwlUdn past year � NaWrel � Homiclde � Drive70perator ��S � NO
<br />W � Ptegna�R at dme of death � Paesen8er
<br />V � AccldaM � Pending Imreatigatlon
<br />a Q Not pregnalrt, but pregnaMwtthln 42 days oideatf� Suldde Coutd nM be determined � P�B��� 21d. WERE AUTOPSY FINDWGS AVAILABLE
<br />❑ ❑ TO COMPLETE CAUSE OF DEATH?
<br />� Not P�eB�aM. hut pre9naM 49 daye to 1 yea► before deafh ❑ ana� �sna�rr� O 0
<br />� Q unknown if PreBnant wUhln the past year . . YES NO
<br />Q ' 22a. DATE OF INJURY (Mo„ Day, Yr.) 22b. TIME OF INJURY ZZc. PLACE OF INJURY•At home, farm, etreet, factory, office bullding, cor�trucUon ske, etc. (Specify)
<br />E
<br />�
<br />.S 22d. INJURY AT WORK7 22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo; Day, Yr.} - - -- � 24a. DATE Sit3NED (MO., Day, Yr.) 24b. TIME OF DEATH
<br />.� � February 9, 2011 � �
<br />g� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF OEATH � k Y 24c. PRONOUNCED DEAD (Mo„ Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />E v Z FebfuB 10, 2011 11:54 PM � a a�
<br />$'� � 9d. To the beat of my knowledge, death ocwrted at the dme, date and place $���� 24e. On the basle of axaminatlon end/or Inveatigadon, In my op�nlon death occurrad at
<br />� e ana aue w ure causet8) smcea. cs�g�awr� a�a rn�e) �� O tire Ume. da6B and placa and due W Ute wueal8) sfat9tl. (Slgnature and Tkle)
<br />� Jane A. McDonatd, MD g s
<br />25. DID T08ACC0 USE CONTRIBUTE TO THE DEATH4 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />❑ YES � NO � PROBABLY ❑ UNIUIOWN ❑ YES � NO Not Appllcable H 28a Is NO ❑ YES ❑ NO
<br />2. E, LE D ADDRE F F S , Y , CO O ER PHY O OUN O EY} (Type or Pr1M
<br />Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />2$a. REGISTRAR'S SIGNATURE �+ � 28b. DATE FILED BY REOISTRAR (Mo, Day, Yr.)
<br />February 14, 2011
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