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� STATE OF NEBRASKA -.
<br />. �,�� � h' � �� ���
<br />' WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND Hl1R�l't����IAI�S `IT'�CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPART DF H€qL�F.I,/�IVD,,
<br />i HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL REC(� �.•' � Fa� ��j `' "_
<br />� �
<br />� ����d��A����� � � �
<br />DATE OF ISSUANCE "�'-'---U'". - � .. r� r.'a�
<br />06/02/2010 STANLEY S. �C�;FJRER ��,�, � �"�. ,' : . �zi �;
<br />2 01 �. 0 5 8 3 5 DE ARTMENT O�I-IEA�TH�D ,,� �� �� a
<br />LINCOLN, NEBRASKA HUMAN SERV��L�S. �•. +jr � � �~, ,, A , �
<br />��� ��?• t�S'�.�,E'�F"�G'��;;:.• 1'�._;�
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES •�•••
<br />� ,: �. ,,.. _ �a�10�0'�1�5;1'0
<br />CERTIFIGATE UF DEATIi " �' !�'i + � "
<br />1. �IECEDENTS-NAME (Flrst, Mtddle, Last, SuHlu) 2. SIX 3. DATE OF QEATH'(1Na; flay, Yr.)
<br />�.a Don Morris Male May 29, 2010
<br />4. �ITY AND 3TATE 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 />��J MOS. DAYS HOURS MINS.
<br />Commerce, Texas 65 April 25, 1945
<br />7. �fiOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />�167-7&2485 HOSPR � InpatleM OTHER ❑ Nursing HomeILTC � Hosplce Facilily
<br />8b; FACILII'Y-NAME pf not Instttutlon, gNe street ami number) ❑ ER/Outpatlent � Decede�'s Home
<br />�
<br />� ,+�226 Manchester Rd ❑ ooa ❑ o�,er (sPeciry>
<br />� Bc: CITY OR TOWN OF DEATH pndude 21p Code) Bd. COUNTY OF DEATH
<br />o �Grand Island 68803 Hall
<br />� 9a. RESIDENCESTATE 9b. COUNTY 9c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />� Sd: STREET AND NUMBER e. APT. NO. 9f. ZIP CODE 8g. INSIDE CITY LIMITS
<br />�` �4226 Manchester Rd 68803 � YES ❑ No
<br />� 10a. MARITAI. STATUS AT TIME OF DEATH � Married ❑ Never Marrled 10b. NAME OF SPOUSE (First, Middle, Last, Sufflx) If wite, give rt�iden name
<br />� ❑ Marrled, but separated ❑ Widowed ❑ Divorced ❑ Unknown PBtfy Aflfl Vang
<br />� 11. FATHER'S-NAME (First, Mlddie, Last, Suffbc) 12. MOTHER'S•NAME �First, Mlddie, Malden Sumame)
<br />m 'pH Morris Frances Watts
<br />°' 13: EVER IN U.S. ARMED FORCES? Glve dates oT servlee ii Yea. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ ,,�res, No, or unk.) Yes 08/06/1965-10/31/1989 Patty Ann Morris Wife
<br />,$ 15. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE 18b. LICENSE NO. 76c. DATE (Mo., Day, Yr.)
<br />F �] suria� ❑ oormnon Not Embalmed June 2, 2010
<br />� Cre�Uon � EntombmeM �gd. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />�'] Removat ❑ Other (Specly) Central Nebraska Crematlon Services Gibbon Nebraska
<br />17i. FUNERAL HOME NAME AND MIULING ADDRESS (Street, CHy or Town, State) 17b. Zip Code
<br />i411 Faiths Funeral Home, 2929 S. Locust Street, Grand island, Nebraska 68801
<br />CAUSE OF DEATH See Instructions and exam les
<br />18.!PART 1. EMer the chain M eveMS--0iseases, h�JuNee, or complicatlona•that dlrectiy cauaed tlte death. DO NOT eMer terminal eveMa sueh es cardlac anest, � ; APPROXIMATE INTERVAL
<br />� respiraMry arteat, or veMriwlar flbriiletlon wtthouS ahowi� the etlology. DO NOT ABBREV WTE. EMer onty one eausa on a Ilne. Add etldtdonal 16res B neceseary. �
<br />° IMMEDIATE CAUSE: ; o�et to death
<br />IAI�MEDUITECAUSE(Flnel a)RespiratoryFailure ; Immediate
<br />disease or wndiHOn �asWtlng
<br />��� DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />s�,��a �� �� rc b) Ghronic Obstrucdve Pulmonary-Disease
<br />apy, leading to the puae Ilated
<br />oh nne a DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />E�ter the UNDERLYING CAUSE C )
<br />(�,iseasa orinJurythatinitlated
<br />the eve�rts reaumng in ueath) DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />�Asr d)
<br />18 PART II.OTHER SIGNIFICANT CONDITIONS-Comlitio� contributing to the death but not resulU� In the umlerlyl� cause gWen In PART L 78. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />� � YES ❑ NO
<br />W 20j IF FEMALE: - 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />� � NM pregnaM wlthin pa8t year � Natural � HoMcltle � DrlvedOperatoY �� � NO
<br />� � Pre9naM at tlme M death � AcddeM � PemUn8lnveatt8atlon ❑ Pe�O �
<br />� Not pregnain, but pregnant wkhln 42 deys ot tleath � PetlesMan 21 d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />�� 3uicltle Could not be detemdnetl
<br />� Not pregnatrt, but pre8�a�rt 43 tlays to 1 year before death � . � � p� �g�y� TO COMPLETE CAUSE OF DEATHI
<br />� Unlmown H pregnaM wfthln the past year � ❑� ❑ NO
<br />°' 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY ZZc. PLACE OF INJURY-At home, farm, street, taetory, oftlee bullding, eonstructlon site, ete. (SpecifyJ
<br />E
<br />0
<br />u
<br />a 22d.INJURYATVPORKt 22e.IIE5GRIBEH�WtNJURYOCCURRED - - -. -- -- ---- --__._
<br />F - -- - --_ `- - -- _ _
<br />❑ YES ❑ NO
<br />221. LOCATION OF INJURY - STREET 8� NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo„ Day, Yr.) 24b. TIME OF DEATH
<br />,�,�,� S�� June 1, 2010 Approx. 12:00 PM
<br />��' 23b. DATE SIGNED (Mo., Day, Ya) 23c. TIME OF DEATN ���} 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />E �� a-' Ma 29, 2010 12:42 PM
<br />$� � O . To the best of m y Imowled g e, tleath occurted at tfre tlme, date and place ��� 2 4 e. O n t h e b a s l s oi e�mminatlon anNor Inveati gatlon, ln m y o pinion death oceurted et
<br />�'�� and due to the cause�e) ataDed. (SlBnature and Tffle) o O p the dme, date and piace and due W Ure cause(s) stated. (SlgnaWre and Title)
<br />'' �$ ~� a Gail VerMaas, Hall Deputy County Attomey
<br />2 � DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ZBb. WAS CONSENT GRANTED?
<br />❑ YES ❑ NO ❑ PROBABLY � UNKNOWN ❑ YES � NO Not Applfcable H 28a Is NO ❑ YES ❑ NO
<br />2,� E, TITLE AND AD RE OF C RTIFIER (PHY ICIAN, YSI S T, COR NE SIC OR A O EY► (iype or P►IM)
<br />" Gail VerMaas, Hall Deputy County Attomey, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />2$a. REGISTRAR'S SIGNATURE �+ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 1, 2010
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