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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALThI Altl� HU�'IAN`S�RILICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORl'GINAL RECORD ON FILE WITH THE NEBRASK�°D�EP��1�EN�' O� �iEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQR �iT/,�.��[;U� �.;
<br />' � 4� Y�. ,�... l�1 ,, : .
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<br />DATE OF ISSUANCE � , , , � � �
<br />2 � 110 5 3�� 5���� S �o���� j�f5 �� .,,
<br />09/22/2010 A����TANT�������E�.i�TR�1�_ �
<br />D�PX�RlMEI�t�" 6t{ f�E,4tF� �4N1� `�
<br />LINCOLN, NEBRASKA flUl►fi�V'SERa/I�ES ,�' °
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES,„, `- "t��,_ ";; s,. ��`� ;. A n nn�ce
<br />CERTIFICATE OF DEATH �- '��"*� �:'' '��.�: ;° �� V6VJV
<br />1. DECEDENTS•NAME (Flrst, Mlddle, Last, Suffix) 2. SEX `""� � e9 n.611TE OF'DEATIi (Mo., Day, Yr.)
<br />Merle Gene Simmons Male ` ` 8eptember 19, 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last Birthday b. UNDER 1 YEAR Sc. UNDER 7 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y�•) MOS. DAYS HOURS MINS.
<br />Kenesaw, Nebraska 77 June 24, 1933
<br />7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />507 OSPITA ❑ Inpatieot OTHER ❑ Nursing Home/LTC � Hospice Factlity
<br />8B. FACILITY-NAME Qf not InsUtutton, give street and number)
<br />� ❑ ER/Outpatlent � DecedeM's Home
<br />� � 4046 Lillie Drive ❑ ooA ❑ other (spectty)
<br />� 8a. CITY OR TOWN OF DEATH Qnclude Zip Code) 8d. COUNTY OF DEATH
<br />c Grand Isiand 68803 Hali
<br />� 8a. RESIDENCE-STATE 8b. COUNTY 8c. CITY OR TOWN
<br />Nebraska Hall Grand Island �
<br />LL 8d. STREET AND NUMBER 8e. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY LIMITS
<br />� '4046 Lillie Drive 68803 � �s ❑ No
<br />. 70a. MARITAL STATUS AT TIME OF DEATH � Married � Nevar Married 10b. NAME OF SPOUSE (Firat, Middle, Last, Suffix) If wife, give maldan �me
<br />m
<br />� ❑ nnemaa, b�c gan�retaa ❑ �nnaoWea ❑ Divorced ❑ Unknown Janice Hargens
<br />� 11. FATHER'S•NAME (First, Mlddle, Last, Suffiz) 12. MOTHER'S-NAME (Flrst, Mlddle, Malden Sumame)
<br />m Arthur Simmons Olive Kind(g
<br />°' 13. EVER IN U.S. ARMED FORCES? Gtve dates of service if Yes. 1Aa. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />$ (vea, No, or unic.� Yes 05/05/1953-05/05/1955 Janice Simmons Wife
<br />,n 1S. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />� ❑ BuHat ❑ Donadon
<br />Not Embalmed September 21, 2010
<br />� CremaUon Q Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY! TOWN STATE
<br />❑ Removal � Other (Specffy)
<br />Westlawn Memorial Park Crematory Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, Cily m Town, S1ate) 17b. Zip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See Instructions and e�cam les
<br />1& PART I. EMer the chain of eveirta•-0iseasae, Injuhes, or complicetions4hat diredty pused the death. DO NOT e�rter terminal everRe sucl� ae cardlac arreat, ; qppRppMpTE INTERVAL
<br />reeplratory arteat, or veirtriwlar flbdllatlon without shmWng the etiolopy. DO NOT ABBREVIATE. EMer only o�re cause on a Iine. Add atltliqonal Iinea if necessary, i
<br />IMMEDIATE CAUSE: ; o�set to death
<br />IMMEDIATE CAUSE (Flnal a) Pancreatic Cancer - Advanced With Mets ; Months
<br />disease or conumon resuffing
<br />��� DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />S�quairtialty Iist conditlona, It b)
<br />- anY. leatling W the eau� Itsted
<br />on Iine a
<br />DUE TO, OR AS A CONSEQUENCE OF: ; o�et to death
<br />E�terffie UNDERLYING CAUSE G �
<br />(tlisease or inJury that InfUated
<br />the everrts resuiane �n death) DUE TO, OR A3 A CONSEQUENCE OF: t onset to death
<br />� d)
<br />18: PART II.OTHER SIGNIFICANT CONDITIONS-Conditiorw contrlbuting to the death but not resulting in the urttleriying cause gWen In PART I. 18. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMEDT
<br />�
<br />� � Nof D�eBnaM witldn �ast Year � Natural � Homiclde � DrlvedOperator
<br />v ❑ Pree�c�u�aa�en �a�aaM �Pendin9lmeatl8adon ❑�"s� 0 ves � No
<br />� Not pregnarrt, but pregna�rt wkhin 42 days M tleatit pedesMan 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />,p � Suldde � Couid not be uetemu�red � TO COMPLETE CAUSE OF DEATH?
<br />� Not pregnaM. 6ut µra8nant 4S daya to 1 Year before death � Other (SpecBY)
<br />� Q Unknown ff pregna�rt withln the past year ❑ YES ❑ NO
<br />a 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, offica bullding, construction sfte, etc. (SpecHy)
<br />E
<br />�
<br />� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />1�-
<br />❑ ves ❑ No
<br />22t. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/iOWN STATE ZIP CODE
<br />� 23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) _ 24b. TIME OF DEATH
<br />- - - _. -- -- - - - -- - -
<br />September 19, 2010 � �
<br />� � 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH � ° 24c, PRONOUNCED DEAD (MO., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />E � Z Se tember 20, 2p10 04:50 PM E
<br />$� � . To the beat of my knowledee, death occurted at the Ume, date and place $!i � pqe, p� ihe basis M examinazion and/or InvesUgatlon, ln
<br />�� and due to the cause(s) ataled. (SlBnature and Tltle ,$ 3� my opinion tleath axunad at
<br />F ) o � p tha tlme, date and ptace and due W the cauae(s) etated. (Signature antl Tltle)
<br />Kimberly A. Mickels, MD ~ "
<br />s
<br />2b. DID TOBACCO USE CONTWBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREDI ZBb. WAS CONSENT GRANTED?
<br />❑ YES ❑ NO ❑ PROBABLY � UNKNOWN � YES � NO Not Applicable if 28a Is NO ❑ YES ❑ NO
<br />27. , TIT E AND ADDRESS OF CERTIFIER (PHYSICIAN, HYS C ASSISTANT, CORON R S PHY I IAN OR CO NTY O El� (fype or Prir�t)
<br />Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATUR� � 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 21, 2010
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