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� , � STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED S�AL OF THE NEBRASKA DEPARTMENT OF HEACT�
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBI2ASKA
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V�,.�
<br />DATE OF ISSUANCE �
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<br />��DE�PART
<br />LINCOLN, NEBRASKA �_�I�hfAN�
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<br />,�E�IlICES, If CERTI�IES
<br />'f f}� f�%�'�tLTH AND
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<br />STA�E REGI
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<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH A(VD HUMAN SEI`tNICES FIIVEW�Q�lFND S1S�l�F'�� °°°' � �
<br />CERTIFICATE OF DEATH �a � ' JLa '
<br />t. DECEDENT'S•NAAAE (Firsi, Middle, Laet, Suffix) 2. SEX ;�`-�' °r, ` (Mo., �ay,Yr.)
<br />Thomas D. Maxon Male � �st a, 2008
<br />' 4. CI7Y pND 87A7E OR TERRITORY, OR FOREI6N COUNTRY OF BIRTH ba. AQE•Last BlrfAday 6b. UNDER 1 YEAR Sc. UNDER t DAY 8. DATE OF 81RTH (Mo., Day, Ycj
<br />�.� ,
<br />(Yrs.) MOS. DAYS HOURB MINS.
<br />Davenport, ATebraslca 5$ March 29, 1950
<br />7. SOCUtL SECURITY NUMBER �� 8a PLACE OF DEATH
<br />�Jo6 yq,�pJl$6; ❑InpatieM 9L� ❑NureingHOme/LTC ❑HosplceFacfity
<br />9b. FACILITY-NAME (1' not lnstitution, g(ve street and number) �1 ER/OutpaUsM ❑ DaoedenYsHOme
<br />3� . Francis Medical Center E. R. ❑� ❑����
<br />8aC1TY0RTOWNOFDEATH (IncludeZipCnde) 8d.00UNTY0FDEATH
<br />Grand Tsland, 68803 Sall
<br />Ba RESIOENGE-STATE �, (xiUNTY gc. CITYOR TOWN
<br />Nebras]ca Ha11 Grand Island
<br />9d. STREETAND NUMBER Be. AP7. NO 9t. ZIP CODE Bg. WSIDE CffY LIMITS
<br />936 3 . LOC119t GS8O1 � YES v No •
<br />� 10a. MARITAL 3TATU3 AT TIME OF DEATH 1 �[Merrfed ❑ Naver Matrfe8 tOb. NAME OF SPOUSE (Firat, Mlddle, Las6 Sufftx) If wiie, gNre maiden name.
<br />❑ Marrled, hut separatetl ❑ Wtdawed ❑ Divorced ❑ Unknnwn S�� M. �3deID8C�ler
<br />1 i. FATHER'8•NAME {Firat, Middle, Last, . Suttix) 12. MOTNER'S-NAME (First, 6Alddie, Mafden Sumame)
<br />Olivez Maxon Elsie Sahoenrock
<br />13. EVER IN U.S. ARMEO FORCES? Give detas ot aervice it ye8. 14e. INFORMANT NAME 14b. RELATION3HIP TO DECED ENT
<br />(Yes,no,orunk.) N� J03l1 �. �XOIl �3.fe
<br />15. METHOD OF DISPQ8t710N 16a ER-SItiNANRE i6b. LICENSE N0. 1BC. DATE (MO.. Dfly, Yr. )
<br />�Bu�� �����, � 1092 � s, 2oos
<br />❑Cremetion ❑ EMOmbment 18d• CEMETERY, CREMATORY R OTHER LOCATION CI'fY /TOWN STATE
<br />❑R�� ❑oma�ts��r�� Aestlawn Memorial Park Cemet�ry Grand Island, Nebraska
<br />I E' : ttaFUNERALHOMEAlAA1EANDMAILIN�ADORE3S {3Vaet,CityorTorm,State) 1�b.ZlpCode
<br />Curran E'unesal Chapel Grand Island, IdE - 3005 So. Locu�t St. ��$A�
<br />'� �. �,,: h
<br />PART I. Enter ihe chein of eveme-diseeaes, fnjurles, or campliradons-that dhectiq ceused the death. DO NOT ertertertninal events etich es cartpacarteat, � �'ROXIDdATE INTERYAL
<br />reapiratary artest, or ventncular ItDriliation arithout ehowing the eNology. DO NOT ABBREVIATE. Emer onty one c�use on a Ana.Add additlonat Ih�ea if necessary. �
<br />� , IMMEDIATECAUSE: � onsetwtleatii
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<br />VdMEC1ATECAUSE(Flnel �
<br />ms�°�com�8on resutU�9 DUE T0, OR AS A CONSEQU�ICE OF: I onsei � death
<br />i �'"�"",�'' UtdeaFh) I
<br />�, � � SequeM�Ilytlstcondttlona,M (b) 1
<br />I
<br />����� DUETO,ORASACONSEQUENCEOF: I onaetmdaeth
<br />.,w f' onlfnea, �
<br />E�ertl�elM�ERIXINO CAUSE
<br />(diaeasewtnjurythatin9leted (c) . . . �
<br />�..� � theeveMer�u9Ngindeaih) .DUETO,ORABACON6EQU�NCEOF: i or�satMdealh
<br />lA��T
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<br />18. PART II.OTHER SIGNIFlCANT CONDITIONS-CandHlona co�ributlng ta the deeth but rrot resulUng in the wMertying cauae given In PART I. 18. WAS MEOICAL EXAMINER
<br />� L OR CORONEfl CONTAC7ED?
<br />�1 YE9 1; NO
<br />20.IFFEMALE: 21aMANNEROFDFATH 21b.IFTRANSPORTATIONINJURY 21aWA8ANAUTOPSYPERFORMED?
<br />`. ❑ DrlvedOParator
<br />O Notpregnant with(n past year �Natural ❑ Hamtcida
<br />����� ❑ YES �NO
<br />0 Pregnant at t(me af deaih ❑ Accident0 Pe�ling ImeaUgadon
<br />❑ Pfotpregnant,butpregnantwithtn42daysotdeath ❑Suldde OCouldirot6adeterm6red �PedesVie� 21d1NEREAUTOPSYFWD1N09AVAllA8LET0
<br />RNotpregnent,butpregnmda3dayatotysarbetoretleeth ❑Other(Speciry) �����DEATH?
<br />❑ Unknown If pregnart witfiin tha past year ❑ YES L�NO
<br />22a. DATE OF INdURY (Mo., Dag Yr.� 22b. TIME OF INJURY 22c. PIACE OF INJURY-At trome, farm, street, teotory, ofNce buitding, construcdon ake, etc. (Specity)
<br />m
<br />22diN,lUHYp7WORK7 22e.DE3CRIBEHOWiNJURY00CURRED
<br />�, . Q YES ❑ N4
<br />� ?Zt. LOCATION OF INJURY • 3TREET & NUMBER, AP7: N0. CRYlfWtM &DQE ZIPCODE
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<br />���r,,.� 23a.OpTEOFDEATH (Ma.,Day,Yr.) Z 24e.DATE3IaNED (Mo.,Dap,Yr.) 24b.TIMEOFDEATH
<br />�� �.� $ � � t71
<br />`„� �� 23b. DATE SI(iNED (Mo., Day, Yt) 23c.Tltd� OF DEATH ��� 24c. PAONOUNCED DEAD (Ma, Day, Yr.) 24d. T1ME PRONOUNCED �EAD
<br />�'°'dZ m �`Z A st 008 1: 4 m
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<br />�'"` ��� 23d.To the basl of my knonuietlge, tleath occurred el tha dlne, date and plece �I �� 24e. On the basls of exeminatlon atlon, tn mycpinion death accuned et
<br />o and due to the ceuse(s) stated. (Signature and TiUe )♦ ��$ the Nma, daie and ue ro the cause(sJ etated (3lgnature and Title )�'
<br />�, �� '" g� Deputy Hal l
<br />25.DIDTOBACCO U3E CONTRIBUTETOTHE DEA'Vli7 28a. HAS OR6AN ORTISSIIE DONATION BEE 81DERE 28b. WAS CON3ENT qRANTE6?
<br />??`-` ❑ YE3 ❑ NO ❑ PROBABLY gl UNKNOWN ❑ YES � NO Not Appllcebie if 28a ie NO 0 YHS � NO
<br />:, 27.NkME,TI'R.EANDADDRES30FCER17FIER (PHYSICIAN,CORONER'SPHYSICIANOACOUNTYA170RNEY) (rypaorPrint)
<br />�°� Aaron Kunz, Deputy Hall County Attorne , 231 S. Locust Street, Grand Island, NE 6880
<br />28a.HEGI3TRAR'SBIaNATURE 1 28b.DATEFlLEDBYREGISTRAR (Mo.,OagYc)
<br />�1 • AUG 12 200�
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