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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,9'L'r �LD�l,M N�RVICES IT CERTIFIES
<br />THE BELOW TO BE A TRtIE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBJ7A�',QE�RTME�'�,.¢F� HEAiTH •AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY F� �1't L �1�� �Rg '"�; 4 A -,
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<br />DATE OF ISSUANCE °' , �� '„ '
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<br />05/18/2010 '' �° ` , , ' " ��'� ",�'
<br />:aS �'D � "� r�,t
<br />,� U 10 3 616 ��:A���sra�-�,a����r�:�r��a �..
<br />a DE�iA?�'1'M NT OF HEAL�`,M I�IWQ, ->
<br />LINCOLN, NEBRASKA f 'F7{ll�,�l'H,�I/IC�� `�'.•.'� .`�.
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERyIC� t � �y��` �`,�tjd � r 10 01340
<br />CERTIFICATE OF DEATH °"a s_�'!11_`q 4 ��r
<br />7� DECEDENTS-NAME (Flret, Middle, Last, Sufffx) 2. SD,C °'- 3: DATE OF 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 - Last BlRhday b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y►s•1 MOS. DAYS HOURS MINS.
<br />� Boelus, Nebraska 95 July 26, 1914
<br />� T: SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />506 osPR � mpaeerrt O_ THER ❑ Nuraing Home/I.TC � Nosplce Faclltty
<br />8b. FACfLITY-NAME (If not Institutlon, gNe street azM number) � ER/Outpatlerrt ❑ DecedenPs Home
<br />�
<br />� � Mary LanNng Memorial Hospital ❑ ooa ❑ Other (SpecHy)
<br />� 8c. RITY OR TOWN OF DEATH pnelude Zip Code) 8d. COUNTY OF DEATH
<br />o Hastings 68901 Adams
<br />� 98. RE3IDENCESTATE 8b. COUNTY 8c. CITY OR TOWN
<br />Z ' Nebraska Hall Prosser
<br />LL 8d. STREET AND NUMBER 9e. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY LIMRS
<br />a , 11968 West Platte R(ver Road 6g883 ❑ ves � No
<br />.� 10a. MARITAL STATUS AT TIME OF DEATH Q MaMed ❑ Never Married 70b. NAME OF SPOUSE (First, Middle, Last, Sufiz) If wfie, gha malden rtame
<br />�'❑ nm,maa, but separated � Wldowed ❑ D(vorced p u��own
<br />� 11. FATHER'S-NAME (Flret, Middle, Last, Suffhc) 72. MOTHER'S-NAME (First, Middle, Malden Sumame)
<br />m � Royal Bishop Onda Unknown
<br />°' 13. EVER IN U.S. ARMED FORCES? G(ve dates of sarvice It Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />£
<br />$ (Yes, No, or unk.) No Joe Lilley Son
<br />, 15. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 16b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F � Budal ❑ DonaUon
<br />Derek Apfel 1240 May 14, 2010
<br />0 CremaUon ❑ EnWmbme� 76d. CEMEfERY, CREMATORY OR OTHER LOCATION CITY/TOWN 9TATE
<br />❑ Removal ❑ Other (Specify)
<br />Juniata Cemetery Juniata Nebraska
<br />17a. FUNERAL HOME NAME AIdD MAILING ADDRE3S (Street, City or Town, State) 17b. 21p Code
<br />Apfel Funeral Home, 411 W 11th St., Box 126, Wood River, Nebraska 68883
<br />CAUSE O DEATH See instructlons and exam les
<br />1& PART I. EMerthe ahain of eveMe•Klisessee, InJuriea, or eompliCatlons-that dlrectiy cauaed the death. DO NOT eirter terminal eve�rts eucA ae cardiec artest, ; qpPROXIMATE INTERVAL
<br />respiratory artest, ar veMHcular flbdllatlon wkhout ehowln8 the etlology. DO NOT ABBREVIqTE, Frrter onty one cau� on a Ihre. Add addWormt Ii�rea B necessary.
<br />IMMEDIATE CAUSE: ; orreet to tleath
<br />UNMEDIATE CAUSE (Flnal e) Cardiopulmonary Arrest ; 10 Min
<br />dlaease or corMidon resuitlng
<br />�� d �� DUE TO, OR AS A CONSEQUENCE OF: ; o�et to death
<br />SAquential�y�latcontlWone,H b)Cachexia
<br />ehY. Ieading W Ure cauae Ilated
<br />on Iirre a
<br />, DUE TO, OR AS A CON5EQUENCE OF: ; onset to death
<br />E'irterthe UNDERLYINO CAUSE �) Advanced Age
<br />(disease or InJury Uwt Mltlated
<br />tiie eveMs resuMing In death) DUE TO� OR AS A CONSEQUENCE OF: : o�et to death
<br />tdsT d)
<br />78 PART II.OTHER SIGNIFlCANT CONDITION3-Condkions wMributl� to the death but not resulUng In the undertyf� cauae gNen In PART I. 18. WAS MEDICAL EXAMINER
<br />Esophageal Obstruction OR CORONER CONTACTED7
<br />C: ❑ YE9 � NO
<br />LL 20 IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMEDT
<br />� Q Notpregnantwlthinpastyear � n� � Homldde � DrivedOperaWr
<br />❑ YES � NO
<br />� PregnaM at tlme ai death � q�qdeM � Pending Imestlgadon ❑ Pa�O8
<br />� Na pregnazrt, but pregna�rt wkhln 42 daye oi death � p8destHen 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />a � Suicide � Coula not be demrminad TO COMPLETE CAUSE OF DEATHT
<br />�] Not P�eB�. but pregneM 49 daye M 1 year before death � Other (SPe�KY)
<br />� � UnknownNprepna�rtwlthinthepastyear ❑ YES ❑ NO
<br />� 22�. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, fartn, etreet, Tactory, offlce building, construction alte, etc. (Specify)
<br />�
<br />.� ZZd. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F�
<br />❑ ves ❑ 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 SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />s� May10,2010 �.��
<br />� � 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH y° 24c. PRONOUNCED DEAD (MO„ Day, Yr.� 24d. TIME PRONOUNCED DEAD
<br />E� Z Ma 11, 2010 03:00 AM ����
<br />��� � . To the beat ot my knowledge, tleetl� occurted at the dme, date and pface $� � 24e, On the baeis of exeminatlon and/or inveatigatlon, In my opinlon deatd occurretl at
<br />F e n d d u e W t h e c a u a e( s) s l a t e d, ( S l g n e t u r e a m 1 Y t t l e) ��� the dme, date and plaee and due to the cause(s) slated. (Slgnature and Title)
<br />$ Richard French, MD � ;
<br />25� DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTEq?
<br />. Q YES � NO ❑ PROBABLY ❑ UNKNOWN [] YES � NO NotAppllcable N28a Is NO ❑ YES ❑ NO
<br />27: NAME, TI AND ADDRE F RTIF ER (P Y IC , HYSIC IST T, ORO ER'S P I R O NTY A 0 NEI� ype or rir�
<br />Richard French, MD, 2115 N Kansas Avenue, Hastings, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE �- 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />May 14, 2010
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