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4655 5 C~eve_a~nol,--
k(~ls~ein /VE X08950
IIVI~IYIIIeIIIIVINIIP~
NUM ~,O.Se~an~~ Orin~.n )Toi,~/~
RD. COMP X G~ //- od
COMPARE ~/d~
CADAS ~ AO
ADAMS COUNTY, NE
INS? N0. F;GUO~~'2~'~'
Date1J..3o_07Time a'd8 ~
" REGISTER OF DEEDS
The Glut `:Uae-Ku~~ o~ Loth 7, z, 3, aad 4, ¢LL~ in
l3~ock 77, Vi~~r~ge o~ /2o~e~¢ad, Adamh Couaty, Ne~2ueka
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STATE OF NEBRASKA
WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HE
SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIC
THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STi
THE LEGAL DEPOSITORY FOR VITAL RECORDS.
DATE OF ISSUANCE
(BAR ~ ~ ~QO~ - ~ ~. __-
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LINCOLN, NEBRASKA ~ ,, ,,HE
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STATE OFNEBRASKA-DEPARTMENT OF HEALTH ANDHUMAN SER
CFRTI FIf'.ATF nF'IIFATH
1MANSERVICES
~6TANLEY S'~OOP!
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1. DECEDENT'S~NAME (Fhsl, _ Midtlle Lasl, Sulhx) •
2 SEX" '~~~
3. DATE OF DEATH (Mo„Day, Yr.)
~~r:( ~ Donald J. Conwa~ ~ ~ ' Male ' ~ Feb. 1 5, 2006
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~r~r 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTR'/ OF BIRTH 5a. AGE-Last Birthday 56. DNDER.1 YEAR 5c. UNDER 1 DAY :6. DATE.OF BIRTH (Mc., Day, Yr.)
~
k~j (YrsJ MOS. DAYS HOURS MINS.;'
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' Nebraska
Red Cloud 59 June 8
1946
.
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fi ?.SOCIAL SECURITY NUMBER / fia PLACEOF DEATH
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1+~,, S Q 7 - 6 4 - 8 21 7 HOSPITAL ^ Inpallanl OTHER: ^ Nursing HomeILTC ^ Hospice Faclllly. -
. _
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u _ _. _ __- _.,___ .... _ __ -
-Bb.FACILIT'!-IJAME (II not inslilu lion, give slreal and number) '
^ ER/Oulpatienl $ Decedents HOme
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x;L^ 911 2 .S. -LlnCOlII ~^ D]1 ^Other (Specily)
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-:, ,J.i,~ Ba CITY OR TOWN OF DEATH (Include Zlp Code) Bd. COUNTY OF DEATH
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y-u~`~n 'Roseland Adams
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~ 9a.RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN '
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Nebraska
Adams ' Roseland
~a ~`pF 9d.STREET ANO NUMBER ~ 9e. APT. NO eL ZIP CODE 9g. INSIDE CITY LIMITS
?i"~-: .911 2 S. Lincoln-P.O.Box 1850 689.73 R(ves ^ No
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10a. MARITAL STATUS ATTIME OF DEATH ~Merrled ONever Married fOb. NAME OF SPOUSE(Firsl, Middis, Lasl, SUlllx)Il wile, give maiden name.
i
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sy'ah' ^ Menled, but separated ~ Widowed ~ Divorced ^ Unknown
Anita Giger
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"'~~' 11. FATHER
S-NAME (Flrsi, Middle, Lasl, Sulllx)
L~9 Conwa 12. MOTHER
S-NAME (First, Middle, Malden Surname)
DeNeldo Thom son
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13. EVER IN U.S. ARMED FORCES?Give datesel service ilyes.
14a.INFORMANT-NAME
"14b. RELATIONSHIP TO DECEDENT
AS?
~:x
(Yes, no,orunk.)~_ _ my _ _
Anita Conway
Wife
+'~'ef; 75. METHOD OF DISPOSITION 16a.EMBALMER~SIGNATURE ~
~
~ 166. LICENSE NO. 16c. DATE (MO., Day, yr.)
Ali6 ~ SitBudal ^DOnagon .('~'
' .~{y ~~, ~Q~- ~' Feb. 20, 2006
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^Cremation ^Enlombmenl
16 .CE,!}E4ERY, CREM RY OR OTHER LOCATION CITY/TOWN STATE
,
"""I`"+ Nebraska
Roseland Cemeter Roseland
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(nth;(~i ^Removal OOlher (Specily) ,
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.
'^~ !f 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreel, Cily arTown, Stale) 17b: Zip Code
i"s's it
Nebraska 68956
Smith-Kenesaw
-209 N
Jackscn-Wilson F
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i ,I u~ ; 3 t rt f r' 4 rl r{ F, e d51. b+u 5 ~ f r aR ~ "w .. 1' R +ryy rat 4 u 7{n{I
4; ~k~ .~;tte,~„a.+dx.~r,a~h ~',.j6CA.,4a~~~F,tlCATH;(SpN Lnrfp.ati 5 ~fitl eQ~rnp~3'}~~~~~ mya~3 ,'~ ~^x,s ,,~
h{+~I 10. PART I. Enter lha chain of events--diseases,Injuries, or complicilions~-Thal dlraclly caused the death.DO NOT enter lerminal events such es cardiac erred, APPROXIMATEINTERVAL
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resplralory arrest, ar ventricular llbrlllallo wilhoul showing the etiology. DO NOT ABBREVIATE. Enter only one cause onalina.Adtl eddillonal lines if necessary. I
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~ IMMED TE,¢AUSE: onset to death
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IMMEDIATE CAUSE (Final (a)
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a I diseasearoandillon resullin
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g DUETO, OR ASAC NA OUENCE OF:w ~_ ^+~ /) ///~ I onsetlodealh
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Sequenllally llsl condlllons, it
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~ any, leading to the cause llsl¢d
DUE TO, OR ASACONSEOUENCE OF: I onset to tlealh
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-,~~4t( on line e, I
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1 Enlerlhe UNDERLYING CAUSE
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_ th¢evenls resullingln death) pUE TO, OR ASA CONSEQUENCE OF: I onset to Oealh
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) ~! 18. PART II. OTHER SI IFICANT CON ITIONS-Condlllons contributing to the death but not resulting In the underlying cause given In PART 1. 19. WAS MEDICAL EXAMINER
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OR CORONER CONTACTED?
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,:f',P}~ ~ ^ YES NO
~+' 20. IF FEMALE: 21a A NER OF DEATH 21b. IF TRANSPORTATIONINJURY 21 c. WAS AN AUTOPSYP RFORMED7
~' I ~Nalural ^Homlclde ^Drlver/Operelar
^NOt pregnantwilhln pall year ~
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OPassanger
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U U Pregnant al lime al death
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^Accidenl^Pending Investigation
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^N0l pragnanl, but pregnant within 42 days Idealh 21tl. WEREAUTOPSY FINDINGSAVAILABLETO
^Suiclde OCould not be tlelermined
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u;A1.a ^Olher (Speelly) -
^NOl pregnant, butpregnan143dayslolyearbeloretlealh COMPLETE CAUSEOFDEATH7
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~ U Unknown it pregnant wilhln the past year ~ ~ ~ ,- _ ~ ^yE5 ~I NO
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U;. 22a. DATE OFINJURY (MO., Day, Yc) 22b. TIME OFINJURY 22c. PLACE OF INJURY-Al home, larm, slreel, laclory, olllce building, conslruclion slle, eta (Specily)
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;c., 22d.INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
f+ 14
~,. 5.
"~!^~~~~"~" 221. LOCATION OFINJURY~STREETB NUMBER, APT NO. CITYlFOWN' STATE ZIP CODE
a; 4
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I` 23e. DATE OF DEATH (Mc., Day,YC) z> 24a. DATE SIGNED (Mo., Day, Yr.) 24h.71ME0FDEATH
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a~ February 15, 2006 a~~
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) 23c.TIME OF ETH msk 24c.PRONOUNCED DEAD (Mo., Day, YC) 24tl.TIME PRONOUNCEDOEAD
u> 23b.D E51G^N~ED (Mo., DDay,LY~r
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e 1 23d. Talhe esl o y knowledge, death occuneq.arlfielime, dale end place ~ w
24e. On the basis of examinallon antllor Invesligallon, In my opinion death occurred el
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' 25. DIDTOBACCO USE CONTRIBVIETOTHE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? 1
1 i ^ YES U NO 7 PROBABLY ^ UNKNOWN ES ^ NO Nol Applicable it 26a Is NO ~ ~/YES ^ NO
;;^i. ~;, 27. NAME, TITLEAND AD ESS OF CERTIFIER (PHYSICIAN, CORONE'S PHYSICIAN OR COUNTY ATTORNEY)(Type ar Print)
,~~ Daniel Mazour M. D.-P.O.Box 547--Blue Hill, NE 68930
26a.REGISTRAR'S SIGNATURE 26b. DATE FILED BY REGISTRAR (MO., Day,VrJ
DEB 2 7 2006
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