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STATE OF NEBRASKA , �= c �"
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH,.�CAI@ �1rlMQIV S�I�IfIC�S, .i'T CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FZLE WITH THE NEBRA.�I�`A �Ir�Y�NY�l1f�'r,CQ� (�CA'L'FH ANQ
<br />HUMAN SERVICES, VTTAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQR -f�l,'�. ,�Ct�R�S '%�, ���� `„�,,
<br />,�"� . .°� ,.y � , �;
<br />DATE OF ISSUANCE p����K���� �' 4��� d d '
<br />S�A�I��' � �q�ER r ` �
<br />08/10/2011 � Q 110 61 � 2 As�g�T �=`
<br />bE�A�T�NEIVT D�_H�'��Ff A1�4, �-
<br />LINCOLIV, NEBRASKA , HLlI�'IA'�f �°7�,VIC�'5' ,+��` �5 y�' �
<br />STATE OF NEBRASKA - DEPARTMHNT OF HEALTH AND HUMAN SERVI'�E$`,.,r. +' �� i� r�,° ���' ,` �+) � O�LG29
<br />�c�r.r.� ��rr �r �r w-ru - ' t��r .
<br />- � VGRIIrIVMIF VI VG/11�� ' "p��� �'.! ; � �
<br />1. DECEDENTS-NAM� (First, Middle, l.ast, Suiflx) 2. SIX ,�'� �, `3. DATE'tlF DF}lTH (Mo., Day, Yr.)
<br />Floyde Rlchard Loy Mate Augu§t 6, 2011
<br />4: CITY AND STATE OR TERRITORY, OR FOREION COUNTRY OF BIRTH Sa. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 bAY B. DATE AF BIRTH (Mo., Day, Yr.�
<br />(Y�•) MOS. DAY3 HOURS MINB.
<br />Broken Bow, Nebraska 64 February 26, 1947
<br />7. SOCIAL 3ECURITY NUMBER 8a. P4ACE OF DEATH
<br />507 osPR � InpaUent OTHER ❑ Nurslnp Home/LTC � Hosplce Facility
<br />86. FACfLiTY•NAME {If nat Instttution, give atreet and number) [] ER/Outpaeent ❑ DecedenYs Home
<br />�
<br />° Saint Francis Medical Center _ ❑ oon ❑ Ather (SpeciTy)
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<br />� Sc. CiTY OR TOWN OF DEATH pnclude 21p Code) 8d. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 8a. RESIDENCESTATE 8b. COUNTY 9c. CffY OR TOWN
<br />w Nebraska Hall Caito
<br />� 8d. STREET AND NllMBER 9e. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY LIMITS
<br />LL P.O. Box 23 68824 � v�s ❑ No
<br />a
<br />y 10a. MARITAL STATUS AT TIME OF pEATH � Marzled ❑ Never Marrled 10b. NAME OF SPOUSE (Flrst, Mlddle, Last, Sutflx) H wHe, give malden nama
<br />� ❑ nnamed but separatad ❑ v�ndowea ❑ oworcea ❑ Unknown Barbara Ann Gascha
<br />� 11. FATHER'S•NAME (Flrst, Middle, Last, Sufflx) 12. MOTHER'S•NAME (Firat, Middle, Malden Surname)
<br />m Kenneth Loy Ruby Bemice Allen
<br />°� 73. EVER IN U.S. ARMED FORCES? Give datea of sarvica Ii Yea. 14a. INFORMANT•NAAIIE 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />� �ves, No, or unk.) Yes 08/29/1968-1?J28/1966 Barbara Mn Lo Wife
<br />, 15: METHOD OF pISPOSITiON 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Oay, Yr.)
<br />F � Burlal ❑ DomaUon
<br />Chris McCoy 1191 August 9, 2011
<br />❑ Cramat�on 0 Eirtombment 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Remowat ❑ Other (SP�KY!
<br />Wood River Mennonite Cemetery Wood River Nebraska
<br />17a. FL7NERAL HOME NAME AND MAILINO ADDRESS (Street, Cily or Town, State) 17b. Zip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE O DEATH See instructions and exam les
<br />t& PART 4 EMer the chaM ot everrts-�dlaeasae, Injuriea, or compll¢atiorrethat directly pused the tleath. DO NOT e�rter terminal everrte such as cartllac arreat, ; APPRpXIPAATE INTERVAL
<br />reapiratory arrest, or vaMricular 8briilatlon without ahowing Ure etiology. DO NQT ABBREVIATE. E�rter ony one cau� on a Ilrte. Add additlonal Ilnes If neceseary.
<br />IMMEDIATE CAUSE: ; onset to death
<br />IMMEDIATE CAUSB (Flnal a) Septicemia ; 36 Hours
<br />di�aw ar conUltlon r�uftlng
<br />�" tl �� DUE TQ; OR AS A CONSEQUENCE �F: 0 o�et to death
<br />sevueiroa�nnstaonamona,n b)AbdominalAbCess : 36Hou�'s
<br />any, leading to the muse Ifated
<br />on Iine a. DUE TO, OR AS A CONSEQUENCE OF: � onset fo death
<br />Frrterthe UNDERLYIN6 CAUSE c) Infected Nephrectomy Site : 10 Days
<br />(diseasa or lnlury that InlUatetl . . . ;
<br />Ure everue resuiung In deaup DUE TO, OR AS A CONSEQUENCE QF: : onset to death
<br />'.nsT d)
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS-Conditions contri6uting to the death but not resultlng In the under{ying cause gNen in PART I. 1S. WAS MEDICAL D(AMINER
<br />Renal Cell Cefcinoma, Renel Failure OR CORONER CONTACTEO�
<br />� ❑ YES � NO
<br />W 2p. I FEMALE: 27a. NIAIdNER OF DEATH 21b. IFTRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />� � Not pregnant wtthin past year � Natural � Hamicltle [] ortverloperator � YES � NO
<br />U! Preg�mnt at tlrtre oi death Passenger
<br />V ❑ � AccIEeM � Pendinp ImesUgadon ❑
<br />� Not pregnant, but pregnaat withm a2 days ot death �] Pedeatrian 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />a � � Suicide Couid not be determirred
<br />❑ ❑ TO COMPLEfE CAUSE OF DEATHT
<br />� Not pregnaM, but pregnaM 43 days M 1 year before tleatb . . � Other (Speclty)
<br />� � Unbcown B pregnant wtthin the past year ❑ YES ❑ NO
<br />a 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURY-At home, farm, street, factory, oftice building, construetlon slte, etc. (Specify)
<br />E
<br />�
<br />,� 22d. INJURY AT WORK7 22e. DESCRIBE HOW INJURY OCCURRED
<br />F�
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />23a. DATE OF DFATH (Mo., Day, Yr.) Z4a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />�' w August 6, 2011 B��
<br />g� 23b. DATE SIGNED (MP•, Day, Yr.) 23c. TIME OF DEATH ��� r 24c. PRQNOUNCED DFAR. (Mo.. �ay,Yr.� 24d. TIMEPRONOUNGED REAO
<br />E � Z Au ust 8, 2011 03:20 PM �� a�
<br />$�� � 3d. To Ute beet oi my knowiatlga, death oCCUrrad at Uta Uma, date and plece �� 24e, On the basls of examination and/or inveatlgat�on, In my opinlon death occurted aS
<br />����� and due M fhe cause(a) atefed. (Signature and TfUe) � �� the tlme, date and place and due to the ceusa(s) stated. (SiBnature and Tifle)
<br />'" � David R. Colan, MD `' � s
<br />25. dID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />� YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Appllcable ff 28a la NO ❑ YES ❑ NO
<br />2. E, RLE D DRESS O TIFI R(P I , Y C I , C RON P SI O U A O EY� (Type or Prinq
<br />I�avid R. Colan, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE �` /".�� 28b. DATE FILED BY REOISTRAR (Mo., Day, Yr.)
<br />L�»
<br />August 9, 2011
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