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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL.DEPOSPtOR3
<br />DATE OF ISSUANCE
<br />04/06/2011
<br />LINCOLN, NEBRASKA ,4+p
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HVMA(44,
<br />CERTIFICATE OF DEATH'
<br />201104417
<br />YCE£.. IT CERTIFIES
<br />111
<br />1. DECEDENT'S =NAME (First, Middle, Last, Suffix)
<br />2.'SEX••,v:�.ia.4µ1:,.
<br />x wplc,� 2fa9 (Md., Day, Yr.)
<br />Mark Anthony Purdie
<br />Mafs ,°''. r
<br />+" MSarth 25, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />AGE -Last Birthday
<br />b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />15a.
<br />(Yrs.)
<br />MOs.
<br />DAYS
<br />HOURS
<br />MINS.
<br />Grand Island, Nebraska
<br />53
<br />March 22, 1958
<br />7. SOCIAL SECURITY NUMBER
<br />Be. PLACE OF DEATH
<br />505-76 -8892
<br />HOSPITAL ® inpatient OTHER ❑ Nursing HOme(LTC ❑ Hospice Facility
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />Bb. FACILITY -NAME (If not Institution, give street and number)
<br />O'
<br />°-
<br />U
<br />-Saint Francis Medical Center
<br />❑ DOA ❑ Other (Specify)
<br />Ow
<br />Be. CITY OR TOWN OF DEATH (Include Zip Coda)
<br />8d. COUNTY OF DEATH
<br />a
<br />Grand Island 68803
<br />Hall
<br />q
<br />9a. RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY OR TOWN
<br />w
<br />Nebraska
<br />Hail
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />9g, INSIDE CITY LIMITS
<br />LL
<br />r
<br />4231 Nevada Avenue
<br />68803
<br />®YES ❑ NO
<br />a
<br />v
<br />18a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />186. NAME OF SPOUSE (First, Middle, Last, Suffix) it wire, give maiden name
<br />v
<br />4:
<br />`m
<br />[]Married, but separated [:]Widowed ❑ Divorced []Unknown
<br />Jody Louise ROdenbaugh
<br />14. FATHER'S -NAME (First. Middle, Last, Suffix)
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Lawrence Purdie
<br />Margaret Thienel
<br />t13.
<br />E
<br />EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />14a. INFORMANT -NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />3
<br />(Yes, No, or Unk.) Yes 06/26/1977- 07/01/1991
<br />Jody Louise Purdie
<br />Spouse
<br />a
<br />15. METHOD OF DISPOSITION
<br />16a. EMBALMER-SIGNATURE 16b.
<br />LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />FD-
<br />® Burial ❑ Donation
<br />Laurie D. Sheffield
<br />1397
<br />March 31, 2011
<br />❑ Cremation ❑ Entombment
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 TOWN STATE
<br />❑ Removal ❑ other (specify)
<br />Fort McPherson National Cemetery Maxwell Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />174. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />68801
<br />CAUSE OF DEATH See instructions and examples)
<br />18. PART I. Enter the chain ofewurm•diseases, Injuries, orcompilcalions •that diractlycausotlthe death. DO NOTmutrtarmisal .ronts ... hig. -ii- metal, i APPROXIMATE INTERVAL
<br />numdr tory .seat, or ventricular 8brlihtlon without showing the otlology. 00 NOT ABBREVIATE. Enter only one cause on a lino. Add additional lines If necessary.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE jFinal a) Respiratory Failure ! 1 Week
<br />disease or condition leashing
<br />in daatlg DU E TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />seq.emmny list conditions, B b) Pneumonia i 3Weeks
<br />any, leading to the cause listed
<br />on he. a. DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />Eatertho UNDERLYINGCAUSE c) Metastatic Squamous Carcinoma Head And Neck 13 Months
<br />(c lsoase .r Injury that initiated
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: I onsettodeath
<br />LAST d)
<br />18, PART It. OTHER SIGNIFICANT CONDITIONS•Condllions contributing to the death but not resulting In the underlying cause given In PART
<br />I. 19. WAS MEDICAL EXAMINER
<br />Immunosuppression For Lung Transplant; Chronic Renal Insufficiency
<br />OR CORONER CONTACTED?
<br />W
<br />❑ YES ® NO
<br />W
<br />W
<br />20. IF FEMALE: 21a.
<br />MANNER OF DEATH
<br />21b. IF TRANSPORTATION INJURY 21c.
<br />WAS AN AUTOPSY PERFORMED?
<br />E] Not pregnant within past year
<br />® Natural ❑ Homicide
<br />E] O'hmsOperator
<br />❑ YES ® NO
<br />W
<br />U
<br />❑ Pregnant at time or death
<br />❑Accident ❑ Pending investigation
<br />❑Pausongor
<br />WERE AUTOPSY FINDINGS AVAILABLE
<br />a
<br />Not program, but pmgnent within 42 days of death
<br />Suicide Call Id not to tlotvrminod
<br />21d.
<br />a
<br />E] Not meanant, but pleasant 43 days to 1 year before death
<br />❑ other (specify)
<br />TO COMPLETE CAUSE OF DEATH?
<br />awwi
<br />E] unknown if pmgnant within the past year
<br />❑YES ❑ NO
<br />E °•
<br />0
<br />U
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />1 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />m
<br />22d. INJURY AT WORK?
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />I'
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET& NUMBER, APT.NO. CITYrrOWN STATE ZIPCODE
<br />23a. DATE OF DEATH (Mo., Duty, Yr.)
<br />24a, DATE SIGNED (Mo., Day, Yo)
<br />24b. TIME OF DEATH
<br />r w
<br />March 25, 2011
<br />a
<br />DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />a23b.
<br />m w o y
<br />E u Z
<br />Aril 1, 2011
<br />08:05 PM
<br />E° a a z
<br />23d. To the best of re immuh ias, daalh occurred attho time, date and place
<br />s g O 24e.
<br />A
<br />On the basis of a durleallon andlor Investigation, in my opinion death accused at
<br />a°
<br />s
<br />and des to the muscle) stated. (Signature and Title)
<br />p
<br />o
<br />the limo, data and place and duo to the musa(s) stated. (Shmatus, and Title)
<br />William Landis, MD
<br />g
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN
<br />❑ YES ® NO
<br />Not Applicable If 26a Is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CAN ASSISTANT, cORONER S PHYSICIAN OR COUNTY ATTORNEY) (Typo or Print)
<br />William Landis, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803
<br />REGISTRAR'S SIGNATURE I 28b.
<br />DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />128a.
<br />ol�
<br />April 5, 2011
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