|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALT!-G R11� �� �, b�CEu�,�.�fT �€R7
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGIIVAL RECORD ON FILE WITH THE NEBRA5ICA�����MEIYI�'���EAL7H I�ND
<br />HUMAN SERVICES, VTTAL RECORDS OFFlCE, WHICH IS THE LEGAL DEPOSITORY FOR-�VI�L; R����S �+. \ r �' �
<br />� ,� p °� �_ sr "" °. �� � `
<br />DATEOFISSUANCE �������! ��,. ��
<br />� t m � ,
<br />S AA1L�1' �', . p , ; �,
<br />08/10/2011 � 0110 7 6 2 6 � �:� ���,����°�- �� �-�a� ��� ° :
<br />��.
<br />� � D�P�/��'j�{i�"OP�H��1�,�'7'1�/-1�11�� ''' � �
<br />LINCOLN, NEBRASKA /-IC�/�'�%�1v �', ,it�h`�' ,,',����„ ; �.,j �'' ,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE�$4"�� ��Kj�� ��`, �.'��' -_ � � 02629
<br />CERTIFICATE OF DEATH z,,. � ; ,� � ,, ; .��''' .�N
<br />7. DECEDENT&NAME (First, Mtddle, Last, SufPoc) 2. SEX �" � ti �"D'AT � OF',DEATH (Mo., Day, Yr.)
<br />Floyde Rlchard Loy Male ' �°A g st 6, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY B: DATE OF BIRTH (Mo., Day, Yr.)
<br />(YB•) MOS. DAYS HOURS MIN9.
<br />Broken Bow, Nebraska 64. February 26, 1947
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />507 HO SPITAL � InpaUent pTHER ❑ Nursing HomeII.TC � Hosplce Facflity
<br />8b. FACILITY-NAME (If not Instihitlon, gNe street and number)
<br />� ❑ ERIOutpatieM ❑ Decedent's Home
<br />� ' Saint Francis Medical Center ❑ ooa ❑ otner�specny�
<br />� 8c. CITY OR TOWN OF DEATH pnciuda Zlp Codej Bd. COUNTY OF DEATH
<br />c Grand Island 68803 Hall
<br />� 9a. RESIDENCESTATE 8b. COUNTY 8c. CITY OR TOWN
<br />Z Nebraska Hall Cairo
<br />�7 9t1. STREEr AND NUMBER APT. NO. 8f. ZIP CODE 8g. INSIDE CITY LIMITS
<br />�, P.O. Box 23 68824 � ves ❑ No
<br />.p 10a. MARITAL STATUS AT TIME OF DEATH � Married ❑ Never Married 106. NAME OF SPOUSE (Flrat, Middle, Last, Sufflx) H wffe, give malden name
<br />� ❑ n�amed but saparated ❑ wndowed ❑ Dlvoreed ❑ Unknown garbara Ann Gascho
<br />� 11. FATHER'3•NAME (Ftrst, Mlddle, Lask Suffiz) 12. MOTHER'S-NAME (First, Middle, Malden Sumame)
<br />� Kenneth Loy Ruby Bemice Allen
<br />Q ' 13. EVER IN U.3. ARMED FORCES? Give dates of service N Yes. 14a. INFORMANT Y4b. RELA710NSHIP YJ DECEDeNT
<br />E -
<br />$ (Yes, No, or Unk.) Y@3 08/29/1966-12/28/1966 Barbara Ann Loy Wife
<br />,°� 1S. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />f °. � Burial ❑ DonaUon
<br />Chris McCoy 1191 August 9, 2011
<br />❑ CremaUon (] EMombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (SpecHy)
<br />Wood River Mennonite Cemetery Wood River Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (9treet, CKy or Town, State) 17b. Zip Coda
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See lnstructions an euam les
<br />18. PART 1. Enler the chain oi eveMe-.diseasea, Iryuriea, or complicadortadhat dlrectiy caused tha deatfi. DO NOT errter temdnel everrts auch as cartllac ertest, ; ApPROXIMATE INTERVAL
<br />raspiratory arteat, or ve�iculaz flbrillatlon wkhout ahow�ng the etiology. DO NOT ABBREVIATE EMer oniy o�re cause on a ihre. Add adtlttlonal Iirres if rteceaeary.
<br />IMMEDIATE CAUSE: ; onsat to deatfi
<br />IMMEDIATE CAUSE (Flnal a) SeptlCemia ; 36 Hours
<br />� disease or wndiUon �esutting . � � - � -
<br />In death) DUE TQ OR AS A CONSEQUENCE OF: ! onset to death
<br />s��am�nYU�cco�amo�re,rc b)qbdominalAbcess � 36Hours
<br />any, Ieatling to the cau8e Iisted ,
<br />on Ilne a.
<br />__ ___ ___ DUE TO, OR AS A CONSEQUENCE OF: p onset to death
<br />- -
<br />� EMertheUNDERLYINOCAUSE �1lnfected Site -----'-- -��`" -� --"---� � �-- - � .
<br />'-- - 90 f3ays-- - - -
<br />(d�sease oriryurythatinlUated
<br />um eveme reauiune m tleau,) DUE TO, OR AS A CONSEQUENCE OF: 7 or�et to death
<br />� d)
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS-ComilUorte conMbuting to the death but nqt resulting In the undedying cause gban In PART L 18. WAS MEDICAL IXAMINER
<br />Renel Cell Carcinoma, Renal Failure OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED7
<br />IL
<br />� � Not P�e9narU within past year � Natural �� Homlcide � OrivedOperator
<br />U � PregnaM at tlare of death � q�� � Pendln9lmieatl8�on ❑ Passen8ar � ❑�S � NO
<br />�T � Not pregnam, but pregna�rt wkhin 4z uays ot death � Sulciue � Could nM be tletermi�red ❑ Pedestrtan Z1d. WERE AUTOPSY FINDW GS AVAILABLE
<br />�,, � Not pregnant, but pregnam 43 daye to 1 year berore death � Other (Speefty) TO COMPLETE CAUSE OF DEATHT
<br />m � unknownNpregnantwtthmthepestyeaz ❑ YES ❑ NO
<br />E 22a. DATE OFINJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, oftice bullding, constructlon site, etc. (SpecHy)
<br />�
<br />� 22d. INJURY AT WORK1 22e. DESCRIBE HOW INJURY OCCURRED
<br />F�
<br />❑ YES ❑ NO
<br />22t. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo.; Day, Yr.) 24b. TIME OF DEATH
<br />.� �i August 6, 2011 � � �
<br />�� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH �� k y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />° � Au ust 8, 2011 03:20 PM � a�
<br />$� 0 . To the best af my knowladge. death occurtad at the Ume. date and plsce $� �
<br />$ � and due to tfre ca a sfated. (Signature and Tttte) � z� 24e• On tha basls of e�minatlon and/or Imestigation, in my oplNon death occurred at
<br />F , c� �l ) � F°• &� tde tinm� Uet� and-placea�M duo W 16e eausels) efatetl.-(Slgnsture and Fitle� --
<br />! � David R. Colan, MD � ,
<br />2S. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED7 286. WAS CONSENT GRANTED?
<br />i Q YES � NO ❑ PROBABLY � UNKNOYHN ❑ YES � NO Not Applicable H 28a is NO � YES � NO
<br />2. TI L AD CER IFI R(PHYS SI I T, C ONER S PH SI O CO NTY A ORNEI� (Type or Prin )
<br />David R. Colan, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGI$TRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 9, 2011
<br />
|