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STATE OF NEBRASKA r
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA LWPA 27?MMt OF~HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FORV1.TAL" k&C6Rbi r ! ,
<br />DATE OF ISSUANCE '
<br />" Ids 3 ,
<br />05/26/2009 20120477 sntLEs CaopER
<br />A~;rsTAN ~TAt~ R~GIS~~ai~,:QE ART NT ~F'HEoif~'/Ht1
<br />LINCOLN, NEBRASKA fl(ItIAN S~RVI~ES; ` " `y
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERYICf^~
<br />CERTIFICATE OF DEATH •0901126
<br />1. DECEDENTS-NAME (First, Middle, Last, Suffix)
<br />2. SEX c t'.t
<br />*";0 TE OF iiWH (Mo., Day, Yr.)
<br />Richard Joseph Homan
<br />Male
<br />~ May.20 2009
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE -Last Birthday
<br />b. UNDER 1 YEAR
<br />Sr- UNDER 1 DAY
<br />8, DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y-)
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />Cedar Rapids, Nebraska
<br />71
<br />September 19, 1937
<br />7. SOCIAL SECURITY NUMBER
<br />Be. PLACE OF DEATH
<br />505-50-7473
<br />HOSPITAL ❑ Inpatient OTHER ® Nursing HomeILTC ❑ Hospice Facility
<br />Bb. FACILr Y-NAME (if not Institution, give street and number)
<br />❑ ER/Outpatlent ❑ Decedent's Home
<br />U
<br />St. Francis Memorial Health Center LTC
<br />❑ DOA ❑ other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />ed. COUNTY OF DEATH
<br />B
<br />Grand Island 68803
<br />Hall
<br />I
<br />9a. RESIDENCE-STATE
<br />fib. COUNTY
<br />Sc. CITY OR TOWN
<br />W
<br />Nebraska
<br />Hall
<br />Grand Island
<br />LL
<br />9d. STREET AND NUMBER
<br />e. APT. NO.
<br />Of. ZIP CODE
<br />fig. INSIDE CITY LIMITS
<br />2525 W. Anna St.
<br />68803
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH [@ Married ❑ Never Married
<br />10b. NAME OF SPOUSE (First, Middle, Last. Suffbt) H wife, give malden name
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />Johanna Jordan
<br />11. FATHER'S-NAME (First, Middle, Last, Suffix)
<br />12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br />m
<br />Mathias Homan
<br />Marcella Goering
<br />E
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes.
<br />14a. INFORMANT-NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />(Yes, No, orunk.) YeS 01/03/1961-11/20/1962
<br />Johanna Homan
<br />Wife
<br />1S. METHOD OF DISPOSITION
<br />16a. EMBALMER-SIGNATURE
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />H
<br />❑ Burial ❑ Donation
<br />Not Embalmed
<br />May 21, 2009
<br />® Cremation ❑ Entombment
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Specify)
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />68801
<br />CAUSE OF DEATH See instructions and examples)
<br />1e. PART 1. Enter the chain or events--diseases, Injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, ; APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the edology DO NOT ABBREVIATE Enter only one cause on a line. Add additional Ibrea H necessary.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final a) Chronic Obstructive Pulmonary Disease E >5 Yrs
<br />disease or condition resulting
<br />In der) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />SequenMy list conditions, U b)
<br />arty, leading to the cause listed
<br />on line a DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE C)
<br />(disease or'.Jury that Initiated
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />Atrial Fib
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />W
<br />LL
<br />0. IF FEMALE:
<br />21a. MANNER OF DEATH
<br />21b. IF TRANSPORTATION INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ Not pregnant within past year
<br />® Natural ❑ Homicide
<br />❑ DrivaAOpendar
<br />❑ YES ® NO
<br />W
<br />Pregnant at time of death
<br />❑
<br />❑ Accident ❑ Pending Investigation
<br />❑ Passenger
<br />t)
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />Suicide ❑ Could not be determined
<br />❑ Pedestrian
<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />EATH?
<br />US
<br />O
<br />•
<br />❑ Not Pregnant, but pregnant 43 days to 1 year before death
<br />❑ Other (Specify)
<br />TO COMPLETE CA
<br />E
<br />F D
<br />p
<br />❑ Unknown if pregnant within the past year
<br />❑ YES ❑ NO
<br />E
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />22a. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />1
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CI YJTOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 20, 2009
<br />12
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m 23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />'
<br />24c. PRONOUNCED DEAD (Mo, Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />May 21, 2009
<br />09:30 AM
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<br />. To the best of my knowledge, death occurred at the time, date and platy
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<br />249. On the basis of examination andlor Investigation, In my opinion death occurred at
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<br />the time, date and place mid due to the cause(s) stale
<br />a8 Jennifer L. Brown, MD
<br />~
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ® YES ❑ NO
<br />Not Applicable If 26a Is NO ❑ YES ® NO
<br />2. NAME, TITLE D CERTIFIER H R ER PHYSICLM OR COUNTY ATTORNEY) (Type or Print)
<br />Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE A&
<br />z
<br />28b. DATE FILED BY REGISTRAR (Mo, Day, Yr.)
<br />CA -
<br />W
<br />May 21, 2009
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