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STATE.OF NEBRASK�4
<br />WHEIV TH1S COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTlFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS S�,CFION, WH/CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. T- '`'-, .. ��
<br />�'���1� � y ' '"�" -
<br />DATE OF ISSUANCE ,`' � �il ����OP�'R '
<br />� �90� ���0�� 2 0110 4 0 6'7 ass�srm�r�s��rr�RE�r��,�.� `` J
<br />LINCOLN, NEBRASKA HEAL F k I A N p� H U M. 4 N �' 6� V' f t,� E� ;�
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<br />- ----- --- ------- -- - - --- . .�- ,
<br />� �- �
<br />,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMf1lNa�RVf�E�� �� 4 tr
<br />CERTIFICA F DEAT ',' ' � � � � ��:��
<br />a� : �. .; 4 (
<br />1. DE ENTS-NAME (Flrsf, AAfddle. Last, 8�c) , �'' 4; 3. DA'f� E (AAWAaY.Yc)
<br />�.•, t�Y L l✓y�KT, W� +-: ,. w `
<br />Do y Alice McPhilli s Feltaat�, �,''` �-�'oVem 2�'2007 ,
<br />4 D STATE OR TERRITORY. OR �REItiN COUNTRY OF BIRTH 8a AOE�Lest 6lrthdey 8b. UNDER 1 YE/lR 6a UNb�R 1 OR`CL :, .,� C1A7E . F SIR'1'H iA@O:. L�aY. YW
<br />(Yte.) M08. DAYB HOURS AsWS:' '
<br />St. ward, Nebraska 77 May 21,1930
<br />7. &ECURttY NUMBER 8a PLACH OF DEATH
<br />�
<br />5 0-8980 H�'� ��� 0 -� 7 LSC Q Nursirtg Homa/LTC � HoBplee Faollity __
<br />� Bb. F •NAAAE (H trot 6istl4NCn. 81ve atreet mM munbe►) ❑�ne� ❑ DecedeiR'e Hort�
<br />c
<br />Sain rancis Medical Center � D0A �
<br />-� Bc. OR TOVYN OF DEATH (Include Zip Code) 8d COUNTY OF DFATH
<br />� Gra Island 68803 Hall
<br />a 8a IDENCE STATE 9b. COUNTY 8c. CITY OR TOYYN
<br />�
<br />LL
<br />�, Neb ska Hall Grand Island
<br />� 9d AND NU698ER 8e. APT. NO. 8L aP CODE 8g. IN91DE t�7Y LI69T8
<br />304 . 10th St 68801 � Y� ❑ N°
<br />� 70a A1.8TA7718 AT TIME OF DEATH � EAerrled ❑ NaverlAertied 106. NA01E OF SPOUSE (Ftrst, ANddle, Lasl, Suflhc) BwiTe, give matden name.
<br />� �' ��� � �" � D1voi � 0n1aiot James McPhillips
<br />� 1t. F ER'8-NA69H (Flrst, AAlddle; LasR Sufflx) 12 AA01'HER'&NANlE (Fpst. d9lddle, Idaiden S�m�eme�
<br />�� Ch es Keller Margaret Yokley
<br />� 73. IN U.& ARAlE� FORCP�? Give datea ot servlce H Yes. 14e. INFORMANT:NAME 14b• RELATtONBHIP TO DECEDENT
<br />I
<br />n�, ,munk► Np James McPhilBps Husband
<br />16. M OD OF DISP08ITION 18a EEABALMER�91CiNATURE 18b. I.ICEPlSE NO. 18c. DATE (AAo., Day, Yr.)
<br />0° � Not Embatmed November 3, 2007
<br />n �E�uombmeM
<br />�� 18d.CEMETERY,CREbATORYOROTHERLOCATION CITY/TOWN $TATE
<br />Central Nebraska Cremation Service Gibbon Nebraska
<br />�� 17a. � NERAL HOME NAAAE AND MNLINfl ADDRE88 (Streey CHY or Town, Stete) � 7b. 7Jp Cade
<br />Ja n-Greenway Funeral Home, 411 O Street, PO Box 112, St. Paul, Nebraska 68873
<br />CAUSE OF DEATH (3ee instructions and examples) �
<br />ta P L Bmertlta d�sM wevarrts . die�ea, upuries, or eomP�mtla�s.Met diweflY raueed tlre death Do Noisnmrtmminal everte euah as certme m�ast. APPROXIMATE INTERVAL
<br />a�t, mwNReWeflfDri08fIM without showin9 flre BllWOpY.00 NOTABBREVIA'fE. EMBfoNY olro eeuse Oa a Q�. Add ed�NOMI Wma 8 rteaeenry.
<br />16AAAEDUITE CAU8E: Orreet M death
<br />IM1p61 TE CAUfiE (Flnal
<br />� �"�"'�'�"g e' u L' ,�, 6 e.v� Y
<br />�' WE TO.OR AS A CON8EQIJENCB OF: � � m��
<br />y ust sorMitlona �
<br />enY� le to the ca�a Itsted b)
<br />O° DUE T0, OR AS A IXINSEQUENC@ OF: � m�
<br />EMer UNDERLYINO CAUSE z)
<br />( ��� ���� DUE TO, OR AS A CONSEQUENCE OF:
<br />onset to daeth
<br />ttm ev resuttlne in deatliJ
<br />LAST
<br />, di
<br />1& P T LL OTHER SIGNIFlCANT CONDiT10N9-Cond(tlons contri6uting to tha deaM but rrot r�ultlrtg In fha undarlying eauaa given In PART L 79. WAS MEDICAL EXAMINER �
<br />OR CORONER CONTACTED?
<br />❑� �
<br />LL 20. I 21a. ANWNER OF DPATH 21h. IF TRANSPORTATION INJURY 21a WA8 AN AUTOPSY PERFORMFD?
<br />� .�nn�n r,�e r� ,,�eL,� p H�aaa ❑ �+�rrca�m� ❑ r� �r'ic
<br />❑ et Ume o! death ❑ Aec(dent ❑ ParMin9lrrrestl8adon ❑ P��88� 27d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />.❑ N u�s w��n � aa a� w a� ❑ sm��ae ❑ c�d �,a � a�m�a ❑ Pade�rian TO COdfPLETE CAUSE OF DEATH?
<br />3' ❑ t, but PreBnaM43 days to 1 year beto�e death ❑ or� csa�r) ❑ v�s .�aa�
<br />� ❑Un HpregnaMwkhinthePeatYea►
<br />� 22a. TE OF INJURY (AAo., Dey, Yr.) 22b. TId1H OF WJURY 22c. PLACE OF INJURY-At home, Tenn, street, faatory, ofttee buD�llng, ac�retn+ctlon s!ffi, eta (SpeeHy)
<br />O 22d. .IURY AT WORK4 22a. DESCPoBE HOW INJURY OCCURRED
<br />�" YES ❑ NO
<br />2211 TION OF WJURY - STREET 8 NUMBER, APT. NO. CRYROYYN STATE ZIP CODE
<br />23a. DATE OF DEATH (E9o., Day, Yr.y 24a DATE SItiNEO (IN0. Day, Yr.y 7A6. TUAE OF DEATH
<br />.�� •. 2. _ B �I ,���` m
<br />� 23b. DATE Slt}NED (AAa, Day, Yr.) 23e.'fIME QF DEATH Y O 24c, PRONOUNCED DEAD (EAo., Dey, Yr.) 24d. TIME PRONOUNCED DEAD
<br />z
<br />E� /�.�'Z�o� 2; j�� �� m
<br />�� 23d. To tlie b�t o1 rtry Imowiedge� death o¢eurted at tlre tlme, dab a�tt! plaee $�� 24e. On fhe basle af e�ceminetlon mid/w inr�tl9aticM �n ruY WilNon deffih o��ur�
<br />�� and du tlte � sTated �ertd Tltle ,� „ Q at tlre tlme� dete m�d piace and due to fhe ceuse(s) eteted. (819nadue atM THie)
<br />d 50
<br />ze. roeacco use carrrsisurE ro rHe uEn,ni� �. �u+s oROaN oa nssue now►noN e� cowaw�r zen. was coNSeNr aeaNrEO�
<br />❑ NO ❑ PROBABLY ❑ UNIWOWN ❑ YE8 Np Noi Appllcable It ZBa Is NO �ES � NO
<br />27. E, TITLE AND ADDRESS QF CERTIFlER (PHYSICIMI. CORONERS PHYSICIAN OR COUNTY A7TORNEI7 (Type or Print)
<br />�///� C'f �/ /�i - ��9' �/'� Cl�s? ` � .S�/��✓U �" ��CZ
<br />28a 81dNA7uRE �b. DATE FlLED BY REC3tSTRAii (Nlo., QaY. Yr.J
<br />P � NOV � 2007
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