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` � "'� ` STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT QF HEALTH AND MUMAN SERVICES, IT CERTIFIES
<br />THE B�LOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE IYEBRASIG4. �.E�A��1�(T Q�' HEA{,TH AND
<br />HUMAN SERViCES, Vli'AL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VL�4'L,R .; �' �+ ,;
<br />"' , '' � ,��,�. �
<br />DATE Of ISSUANCE ��, ... P�� ;����� >
<br />f � s�"<4.�'� ��o,P.�� .• , '. r ,�
<br />.IUN 2 e� �0�9 � � � � � � ( O / DE�IRTM1 STATE RE��7�2.�� '�,e . '
<br />LINCOLN, NEBRASKA l;fU�ti4 ,N S���/'►f�� �" ' ` '�
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<br />STATE OF NEBWI3KA - DEPARTMENT OF HEALTH AND HUMAN SERVIt(�ES1,� r r1 �'� �• �
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<br />1. D�EDENT&NAlAE (Fdtit, AAtddle. Last, �) 2 SEX 9 L�ATE 'DEA �(BA�,OaySYr.)
<br />\ . � � � � . . ; �<��a ..
<br />illiam Lewls Fowles 1rID Male November 10, 2010
<br />4. CITY 1WD STATE OR TERRITORY, OR FOREION COUNTRY OF BIRTH Ba AOEt.o! BMhdey Bb. UNDER 1 YEAR Ba UNDER 1 DAY & DATE OF BIRTH (EAa, Dey, Yr.)
<br />(Y�s.) Al08. PAYS HOUI� NfIN&
<br />Goleridge, Nebraska 68 • May 15, 1942
<br />7. SOCIAI. SECURITY NUMBER � Ba. PLACB OF DFATW . ' � .
<br />�� �aPet�t ,4�E&Q N�as4�9 Homell.TC � Hoapice Fec�Ry
<br />�b. FACIUTY•NAAAE � �rot I�tiddion. 8We street mrc! munberj ❑ EWOutpatleM ❑ DeaedenCa Home
<br />Alegent Health Immanuel Medical Cerrter . � �
<br />e�. cmroR roaur� oF near►i �,�a�np c�� aa. cour�n oF oearr�
<br />Amaha 68122 Douglas
<br />8a. REBIDENCE37'ATE Bb. COUNTY 8c. CRY OR TOWN
<br />LL
<br />�, �Nebraska Hall Grand Island
<br />�p �d. 8TREEr AND NUdIBER 9e. APT. NO. 9f. �P CODB 9p. INSIDE C11Y LtASIT3
<br />� - � , . . . � . . Yea � No
<br />�8Q8 Cottonwood Road 68801 � ❑
<br />� 40a MARRAL 8TA'RIS RT TpME OF DEATH � Mmied 0 Nerer EAmHed 70b. NdME OF SPQUSE (FUs; I�idt�e, le�. S�rtflu) B rrlfe, 9� malden nartte.
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<br />�� [p eee�ea. �,cse�ma p wu�a ❑ w�o,�a ❑ uoww.m Kathleen Cronin
<br />� , fi�. Faniexaw►nue �Flrs�, ewame, �e, s�� �z eeorri�rs-w�xe c�e. xuam�, aemd.n s�menre)
<br />1p '�ewis Fowtes Arlene M
<br />m. 13. EVER M U.B. ARAlm FORCES7 CiWe datea 4f emrice BYee. 74a INFORd1ANT NAAAE � 74b. RELATIONSH� TO DECEDENT
<br />H
<br />;tYes,No.orunt6t Y8s 07/1869-07/1971 1CethtEen FoW18s Wlfe
<br />1& METHOD OF DiSPOSITION 18e. EMBALMRR.RI�NATURL' 18b. UCEN �� 78e. DATE (Mo., Day, Yr.) ,
<br />� ��' 0�' November 76, 2010
<br />�, ❑�o� p�u� . '
<br />QRemmra� Qotheq9Pmlryl 18d. CFJIAETQtY. CREl9ATORY OR 071iER LOCATtON C1TYl1'OWN STATE
<br />Cirand Island City Cemetery Grand Island Nebraska
<br />17a FUNERAL HOME NAdIE AND YAWNO ADDRE88 (Streat, CHy or Tmm, State) 77b. �p C�8
<br />;Apfel Funeral Home,1123 W. 2nd, Grand Island, Nebraske 88801
<br />CAUSE OF DEATH See instructians and exam les
<br />��6.PARTLEmertlla '�4h1J�.meomP��-tlut�aeU7�tlredemll.�WOTaMeJGmmmal�wledleeamdimertaei � � ; APPROXIEUATEINTERVAL
<br />i � �sP�mYerteet,9rne�ptiedarNntOffiMnwChattat�rh�Btlreaitolog7.�NOTABBREYIATEEnL�wdyoreceasaOnaMe.AtldeGt�iWmlPowsH�ry. �
<br />IN@AEDIATE CAUSE t onset to deafh
<br />�m�� �V$E �FlI18� � �' � y
<br />djseaeeorcotaIItlonree�dWig � �a) � � 1/�� . �
<br />�H
<br />In deeth) �
<br />011E TO, OR AS A CONSEQLENCE OF: � onsat to deatfi
<br />�aque�Iel�Y Ilet c�dmre. H b) �, I_ _ : � h1l'�ica�cwCO
<br />anr. �eamm� ro nre cmrse netea tu�Y1 �'L
<br />�� � DU8 TO, OR A8 A CONS UENCH OF:. .. .. . . ; o�reat to death
<br />�mer nre UtauQU.vueQ rrwBE �I
<br />�m�ese or m�r n� imnema
<br />. t'te eve�s� resu�d� fn death) �.DUE TO, OR AS A CONSEQUENCE OF: ; o�sat to deatl�
<br />4^�T
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<br />'�& PART LL OTHER SIOMF[CANT CONDITIONS-CotMltlotm aontribuB� to tl�e death but mt reeWtl� In tlre imdarlyin8 oause gfvan irt PART L �. 19. WAS AAEDICpL E7tAEASWER .
<br />- � � . . . . . OR CORONER CONTACTED?
<br />❑ YES {�NO
<br />� 20. IF FEINALE: - 21a ER OF DFATH 216. IF TRANSPORTATION IPIJURY Z1c. WA9 AN AU70 P�ERFORAAED?
<br />E NALE:
<br />� Not Pregnm�twHMn P�t Yamr �❑ Hcm►clda ❑ Driv�l0�r�r ❑ 7E8 L7 n�
<br />� PregrtaM at dme of death �, ❑ AcddeM .❑ Pe�g drveatlgaflan � ❑ P�Se�er 21d. WERE AUTOPSY FMDINtaS AYAilABLE
<br />� Not pregneny but preg�mnt artthin 42 dapa ot' death ❑&ilalde ❑ Could rat be detenN� ❑ Pedeetrien TO CONPLETE CAUBE OF DEATH?
<br />��� �_j � P►eB�R Eut p►�nent 43 daye to 1 year before deatl� ❑ Othe► (SP�YI ❑ rES p�No
<br />�� Untmown H pregnent wltltln fhe �et y�r �. � � �
<br />C ' ,
<br />� �;27a. Df}TE OF INJURY (Alo, Day, Yr.) 29�.'IIlAE OF INJURT 22a � E OF INJURY-14t homa femi. sVeef, (actoiY. ofllca buUrlln�'aarefrudlon aka. em. (&Pe�NY)
<br />% .m �
<br />'� �;ria wruav Arwot�c� zz�. oESCwee How rowur�r occur�o '
<br />►- �. ❑ yes Q No
<br />N�� -_ - - - -
<br />���22L LOCATION OF �NJURY - STREET & NUMBER, APT. NO. CITYROWN STpTE ap CODE
<br />FV��
<br />T.ia. DATE DP DEATH (AAO., Dap. Yr.) � 24a. DATE SIGNm @Ao., GeY. YcJ 246. TIM@ OF DEATH
<br />� � �l�V � ZOju a v_� m
<br />236. DATE �CiNEp (bfo„ Qay, Yr.f �. TIINE OF DEATH �!�. O 24c, pRONOUNCEC DEAD (Mo., Oey, Yr.) 7Ad. TIdIE PRONOUNCED DEAD
<br />� o �U�V �� �-O�U � C�m � y� � o m
<br />a
<br />230. To fhe 60at W rtry knowledge, death oawared et tha time. dafe a�M placa $�� �?Ae. On ttm baels of e�ninatlon mtdfw IrneaUBatlon. in mY opiNon death occ�med �
<br />e n d aeueats) s�ed: (StenaWre a�a THie) � � ,$ � et the tlme,� aam and p�aee mtd due m me c�s) smtea. (Signewre end'17Ne)
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<br />II � � �.�(,� � � . . _ . . . F" v �p . . . .
<br />II2& OID TOBACCO CONTWBUrQ Tp'ftiE DE/1TH? 28e. HA8 O OR T18S1)E DONATION BEEN CONSIDERED4 28b. WA8 CONSENT (iRANTEq7
<br />ERED
<br />❑ YE8 NO ❑ PR08ABLY ❑ UNKN0INN � ❑ NO No! Applicable M 28a Is NO �YES ❑ N�
<br />�27. NAEAB. TIriE AND ADDRESB OF CERT6IER iP��1AN. PHYSICIAN ASBISTANT. CORONER'3 PHYSiC1AN OR COUNTY AITORNEY) (TYPa or �)
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<br />P I28a RE6I8TRAR'8 81CNATURE �� .... , � , � r 28b. ATE FlLEG BY ���(AAo., DaY, Yr.)
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