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STATE OF NEBRASKA
<br />' WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTK-�1tfJ� H IT CERTIFIES
<br />'TI�E' BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA�I�C p�,��°R'7�i�ILEl1l�',OP'MF�A��H AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAt DEPOSITORY FOR ��'T,AL fZEeQ D�. •; k , �
<br />A
<br />DATEOFISSUANCE � � � ; .� } a'�
<br />.��.d����� �, t�, .
<br />S�'Al1�EY S ,�OOPEId, ;r • � r � �
<br />04/19/2011 � o � � O :3 � � � A��,''�i.l�'AI�T �TA,�.�.�'.�C�T1�f�`: ,,•
<br />DE�tIR.TMENT OF HE��TH'Al�� ':� ''
<br />LINCOLN, NEBRASKA HUI�lA9��S�qk/J'CES p ,y'��`, r_".' `
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES ���ct'�.�'� ,�°'�, �� % 'a_ r.-� �_� 11 01258
<br />��rc� �rwp►� � c�r ur�►� n �� ��, , ,,, �,���r�� �.. ~ ��. •�
<br />1. DECEDENTS•NAME (First, Middie, Last, Suftix) 2. SDC '. ` 3. qA7E OF DEATH (Mo., Day, Yr.)
<br />Leonard Carl Hupf Male °; April 10, 2011
<br />4. CITY AND STATE 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 />' (Y�s•) MOS. DAYS HOURS MIN3.
<br />Holstein, Nebraska 84. April 7, 1927
<br />7. SOCL4L SECURITY NUMBER 8a. PLACE OF DEATH
<br />507-242897 HOSPRAL � Inpatlent OTHER � Nursing Home/LTC � Hospice Facttlty
<br />Sb. FACILITY•NAME (H rrot InsUtutlon, gNe atreet ami number) ��OutpatieM ❑ Decedent's Home
<br />�
<br />� Grand Island Veterans Homa ❑ ooa ❑ otner�spec�ry�
<br />� 8c: CITY OR TOWN OF DEATH Qnclude Zip Code) 8d. COUNTY OF DEATH
<br />o IlGrand Island 68803 Hall
<br />� 9aJ RESIDENCESTATE 9b. COUNTY 9c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL 8d: STREET AND NUMBER e. APT. NO. 8P. ZIP CODE 8g. INSIDE CITY LIMITS
<br />;; 102 W. 22nd St. 68841 ��r�s- Q- No
<br />a 70a. MARITAL STATUS AT TIME OF DEATH Marrled
<br />� � ❑ Never MarHed 10b. NAME OF SPOUSE (First, Middle, Last, Suffbc) H wffe, gNe matden mame
<br />� �] nnamed, nucsepa�ated ❑ v�naowea ❑ oworcea ❑ u�rwwn Pauline Malone
<br />� 11;; FATHER'S-NAME (Firat, Middle, Last, SuH6c) 12. MOTHER'S•NAME (First, Middle, Malden Sumame)
<br />m Henry A Hupf Elizabeth Miller
<br />E 13. EVER IN U.3. ARMED FORCES? Ghre dates of service IT Yea. 14a. INFORMANT•NAME 74b. RELATIONSHIP TO DECEDENT
<br />$ es, No, orunk.) Yes 07/09/1945-12/01/1946 Pauline Hupf Wife
<br />,� 15.'METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE 16b. UCENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F � Btaial ❑ DorreUon
<br />Patricia R. Curran 1092 April 15, 2011
<br />�] Crematlon ❑ Entombmerrt 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />�] Removai ❑ Other (Specfty)
<br />Westlawn Memorlal Park Cemetery Grand Island Nebraska
<br />17 . FUNERAL HOME NAME AND MAIUNO ADDRESS (Street, Cily or Town, Sfate) 17b. Zip Code
<br />�urran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 68801
<br />CAUSE OF EATH S� Instruct ons and exam les
<br />1& PAR71. EMer Ne chaM ot eve��dleaasea, injuqea, or compqcatlorar�that dlrectiy caused fhe death, DO NOT eMer terminat eve�rta euch as cardiac arteet, : ApPROXIMATE INTERVAL
<br />" respiraMry erreet, or verrtricular flbriilatlon without showing the etlology. DO NOT ABBREVIATE EMaz onry o�re muse on a Iirre. Add adtlUlonal Ihres N rtecessary.
<br />i IMMEDIATE CAU3E ; o�et M death
<br />a�owre cause �m� a) Aspira�on Pneumonia ; 4 Days
<br />disease a ccndWon reaulUng
<br />10 ��') DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />sqque�nla�ryl�stconu�done,B b)qlzheimers Dementla, Stage VII �> 1 Year
<br />e, Ieading to the muse tlstad
<br />on�lfne a
<br />DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />(� rthe UNDERLYIN6 CpUSE ��
<br />or Injury that InRlated �
<br />tlre everrte reauitl� In death) DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />� d)
<br />18. PART It. OTHER SIGNIFlCANT CONDITIONS�ComiHtoire contributing to the death but rrot resWUng In the undertylrtg cauae gfven In PART 1. 18. WAS MEDICAL IXAANNER
<br />OR CORONER CONTACTED?
<br />q I ❑ YES � NO
<br />� � 4 20. IF FENL4LE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21e. WAS AN AUTOPSY PERFORMED?
<br />� Not PreBna�rt wlthin Vest Year � n�� � x,,,,idaa p o�noae�w. ��s � No
<br />� PreBnant et dme ot death � AccldeM � Pendle9 Investl8adon ❑ P���'
<br />� Not pregnarrt, but pregnaM wtthin 42 days oi death Q pedeaMan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />� � Na P�nam,�Dtit P�Bnent 43 days ro t Yea�' beTore death .. ❑ Sulclde � Couid not be determined �_ (sP ._ ._. __- TO�QI'APL�E'fE CAi7SE GF 6EATH?
<br />� Unlmown H pregnam wiNUn the past year ❑ YES ❑ NO
<br />£ 22a� DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, atreet, faetory, office building, coneUuction sfta, etc. (Speclfy)
<br />$
<br />.� T2di INJURY AT WORKT 22e. DESCRIBE HOW INJURY OCCURRED
<br />F�
<br />I ❑ YES � NO
<br />22f.i LOCATION OF INJURY - STREEf & NUMBER, APT.NO. CITYtTOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />S April 10, 2011 � �
<br />� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH � � 24c, pRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />��Z A r1114,2011 01:25PM E�<Z
<br />$ O . To the best of my knowledge. death a�curted at the Bme, dete and place $ � 24e. On the � M e�mi�tlon antl/or Inveatigatlon, In my opinlon death axurted at
<br />and due to�the musie(s) s�fed. (818naWre� ar�d Tkle) .$ �
<br />�� F me nore. aa� ana waee ana aue m u,e eau�(818meea. (s�enaWre ena rwe)
<br />~ JenNfer King, MD � g s
<br />25. ID TOBACCO USE CONTRIBUTE TO THE DEATH7 28a, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED7 28b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN � YES � NO Not Appltcable if 26a Is NO ❑ YES ❑ NO
<br />2. T T � RE ERTIF ER IC , HYSI 1 T CORO ER HY IC OR A RNE1� ype or PrIM
<br />�lennffer King, MD, 2300 West Capital Avenue, Grand Island, Nebraska, 68803
<br />28a l REGISTRAR'S SI�NATURE 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />��. .
<br />April 18, 2011
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