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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ,�M{T HUMAN IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA' DEP'AR�fMEN� t7F HEALTH AND
<br />HUMAN SERVICES, V1TAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR ViTAC;I��'GQRp� " i�
<br />'�' ' � e � 4 , 3' ' j
<br />DATE OF ISSUANCE , „ , jR-! _•. _
<br />C�
<br />STANKE� S;'; �Q ° ER � �,' %,
<br />03/06/2012 2 012 0 2 0 6 3 ASSrS�RNT �A� R'�GI5TR.4R "": �
<br />DFPARTJ�%lPNT OF HEALTH AND -; '
<br />LINCOLN, NEBR,4SKA HUMAIIP�FRI/�I,CES '�
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES �',, ����� �' �,,,, � 2 OO74H
<br />AL�TICl/►ATG AL 11L"ATI..1 ° � � � .. .
<br />v��� � u �vr+� � v� vr.� ��■ : r c� -
<br />1. DECEDENT&NAME (First, Mlddle, Lasf, Suffi�c) 2. SDC 3. DATE OF DEATH (MD., Day, Yr.)
<br />Patty June Whitt Female March 1, 2012
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birtlbay b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (MO., Day, Yr.)
<br />(Yre•1 MOS. DAYS HOURS NWVS.
<br />Grand Island, Nebraska 69 October 3, 1942
<br />7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />5�5-52-7452 �❑ Inpatleiu OTHER ❑ Nursing Home/LTC � Hospice FacilHy
<br />8b. FACILITY-NAME (If not Instidrtion, pive atreet and number) � ER/OutpaUent � Decede�rt's Home
<br />�
<br />� 712 N. Broadwell ❑ DOA ❑ Other(Speclty)
<br />�
<br />� 8e. CITY OR TOWN OF DEATH (hrctude 21p Code) 8d. COUNTY OF DEATH
<br />c Grand Island 68803 Hall
<br />� 8a. RESIDENCE�.STATE 8b. COUNTY 8C. CfTY OR TOWN
<br />w iNebraska Hall Grand Island
<br />�7 9d. STREET AND NUdIBER 9e. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY LIMffS
<br />a 712 N. Broadwell 68803 � res ❑ No
<br />n 10�. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Marti�! 10b. NAME OF SPOUSE (Flrst, Middle, Last, Suftix) If wite, gfve malden name
<br />� ,❑ Marned, nut separated � wwowea ❑ otvoreed ❑ unk�rown James Lee Whitt
<br />m
<br />� 11. FATHER'S-NAME (First, N4ddle, Last, Suftix) 12. MOTHER'S•NAME (Flrst, Middle, Malden Sumame)
<br />� Phfllip Donald Van Bibber Thelma Vfola McClurkin
<br />°' 73; EVER M U.S. ARMED FORCES? Give dates oi service If Y�. 14a. INFORAAANT-NAME 14b. RELATIONSHIP TO DECEDEN7
<br />E
<br />s (ves, No, or unk.) No SCOtt Whitt Son
<br />� 15, METHOD OF DISPOSIT70N 18a. EMBALMERSIGNATURE 18b. UCENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F � Buhal ❑ Dorratton
<br />Laurie D. Sheffleld 1397 March 7, 2012
<br />� CremaUOn ❑ Errtombment 78d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />❑ Removai ❑ ar�er (spec�ry) Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CA SE OF DEATH ee Instructlons and exam les
<br />1& PART I. EMer Ne chafn of everAS-�diseasee, InJurlea, or complicadonsdhat dlrecUy cauaed the death. DO NOT e�rte1 terminal eve�e auch as aerdiac arreat, ; APPROXIMATE INTERVAL
<br />reaplwtory arteat, m ventrlcuiar flbrtltaUon rtthout ahwrinp the etlology. DO NOT ABBREVIATE F.�rt9� oNy one cauee on a Wre. Add adGitlonal W�es fl �receesary. •
<br />�
<br />IMMEDIATE CAUSE: ; onset W death
<br />IkIMED1ATE CAUSE (Flnal a) Cardiopulmonary Arrest ; Immediate
<br />diaease or wndidon reauiting
<br />� d � ' � DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />s�em�nr nBe �o�amo�, rc b) High Blood Pressure E Gradual
<br />a�r� �eam� m u,e ca�e nsrea
<br />on Il�re a DUE TO, OR AS A CONSEQUENCE OF: � oireet to death
<br />EMerthe UNDERLYINO CAUSE �) High Cholesterol ; Gradual
<br />(dbeaw or InJury that Inttlate0
<br />the e''B"te'eawd"g In deau'� DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />� d) Hypothyroidism : Gradual
<br />18. PART 0. OTHER SIGNIFlCANT CONDITIONS�omiklo� corrtributing to the death 6ut not resultlng in the u�erlying eause given in PART I. 18. WAS MEDICAL EXANONER
<br />ORCORONERCONTACTED7
<br />� � YES ❑ NO
<br />W 0. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />�
<br />� � Not pregna�u wkhln pastyear ' � Natura� � Hom�dde ❑�Ve��Perato� yES NO
<br />� � Prepna�rt at dme of death � Acdde�rt � PwMI� ImeaUBatlon ❑ Paesenper ❑ �
<br />�] Not prepnant, but pregnantwitmn aa days ot Eeath gmWde CoWd not be determ��reti � Pedestr�an 21d. WERE AUTOPSY FINDINGS AYAILABLE
<br />� � Not plegnant, 6ut prepnazrt 49 tlaye to 7 yeaz 66fore death � �� � � Other (Speciry) TO COMPLETE CAUSE OF DEATH?
<br />� ❑ res ❑ NO
<br />� � Unlmown H prepnant withln the paet year
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURY•At home, farm, street, Tactory, office bullding, eoretruction ske, ete. (Speeify)
<br />c�
<br />� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />❑ YES ❑ NO
<br />22t. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITYlfOWN STATE 21P CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />.� � .� �� March 2, 2012 Approx. 06:30 PM
<br />� r 23b. DATE SIGNED (Mo., pay, Yr.) 23c. TIME OF DEATH �� k 24c. PRONOUNCED DEAD (Mo, Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />$� o ��< Z March 1, 2012 08:22 PM
<br />To the best o1 rtry knowletl8e� death occurted at the dme. date arM ptaze �
<br />8� $� 2Ce. On the 6asls oT euaminatlon anNOr ImeeUB�on, ln my optdon death oeeurred ai
<br />o and tlue to the cause(e) atatetl. (Sipnature and TftleJ � o$ the dme, date and place end dua to the cauee(e) etated. (Sipnature and 77Ue)
<br />'" ~ g 6 Martln Klein, Hall Deputy County Attomey
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREDT 28b. WAS CONSENT GRANTED?
<br />Q YES ❑ NO ❑ PROBABLY � UNKNOWN ❑ YES � NO Not Applleabie H 28a is NO ❑ YES ❑ NO
<br />D IFIE (P I R ERS H I ypeor ►Int)
<br />Martin Klein, Hall Deputy County Attomey, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />28a. REGISTRAR'S SIGNATURE �• 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />March 6, 2012
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