|
STATE OF NEBRASKA 1-2 , 5 75 6
<br />• WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTHAND;HUMAIIi SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIG/NA1. Z, Q°.~` FJLE NA ,,H
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST( E 'f?1 WH, is
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE - '
<br />®I~C AS~IST~PRS7.~#'l ~(~1S~1~
<br />LINCAl1r SKA HEAFI ~1D:kJ)}f SE('1
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCI :Ab I~ u1:)PO( F}T ri= .17 SS
<br />/'_PCIT1=1PAT~ n= 1'1FATF1 j
<br />1. DECEDENT'S-NAME (First, Middle, Leal, Suffix)
<br />2 SEX
<br />3. DATE OF DEATH (Mo-, Day; '
<br />`
<br />Arline Margaret Scott
<br />.
<br />F~3a1e
<br />1
<br />0
<br />30, 05
<br />No
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />6a. AGE-Last Birthday
<br />6b. UNDER 1 YEAR
<br />So. UNDER 1 DAY•
<br />6. DATE OF BIRTH (Mo.; Day, Yr.)
<br />Belfast, Nebraska
<br />(Yrs.) 92
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />December 25, 1912
<br />7. SOCIAL SECURITY NUMBER
<br />Be. PLACE OF DEATH
<br />508-30-9317
<br />HOSPITAL; M(Inpatlent Q FIB ❑ Nursing Home/LTC 0 Hospice Facility
<br />€6 -
<br />8b. FACILITY-NAME (If not Institution, give street and number)
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />St. Francis Medical Center
<br />>
<br />❑ D04 ❑ Other(SpecBy)
<br />Be. CITY bR TOWN OF DEATH (Include Zip Code)
<br />8d. COUNTY OF DEATH
<br />w
<br />Grand Island 68803
<br />Hall
<br />1
<br />go. RESIDENCE-STATE
<br />gb COUNTY
<br />gc.CITYORTOWN
<br />T.
<br />Nebraska
<br />Hall
<br />Grand Island
<br />Bd. STREET AND NUMBER
<br />go. APT. NO
<br />Of. ZIP CODE
<br />9g. INSIDE CITY LIMITS
<br />3230 Nestside
<br />68803
<br />(81 YES ❑ NO
<br />m
<br />10a. MARITAL STATUS AT TIME OF DEATH g(Married ❑ Never Manned
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />E
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />Allen D. Scott
<br />0
<br />V
<br />m
<br />11: FATHER'S-NAME (First, Middle, Last, Suffix)
<br />12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br />m
<br />Jack (NMI) Murphy
<br />Ethel (NMI) Cargill
<br />13. EVER IN U.S. ARMED FORCES? Give dales of service i1yes.
<br />14a.INFORMANT NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />No
<br />Allen D. Scott
<br />Husband
<br />No, no, or unk.)
<br />16. METHOD OF DISPOSITION
<br />16a. EMS SIG E e
<br />16b. LICENSE N0.
<br />16c. DATE (Mo., Day, Yr. )
<br />aBudal ❑Donation
<br />~(~3 7
<br />December 5, 2005
<br />❑ Cremation ❑ Entombment
<br />18d CEMETERY, CREMATORY LOCATION CITY /TOWN STATE
<br />❑Removai ❑Other(Specify)
<br />Westlawn Memorial Park Cemetery, Grand Island, Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />17b. Zip Code
<br />Kleine Funeral Home, 3213 W North Front St., Grand Island, HE
<br />68803
<br />CAUSE O:F'DC'ATH (See (ns 0gtions'and exanlpfcs)
<br />18. PART 1. Enter the chain of events diseases, tn)urles„or comphcafiona--that directly caused, the death. DO NOT enter terminal events such as cardiac arrest, i APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause an a line. Add additional lines It necessary. i
<br />IMMEDIATE CAUSE: o i onset to death
<br />^ ti
<br />IMMEDIATECAUSE(Ftrml
<br />1
<br />disease croondift resui8ng DUE TO, OR AS A CONSE ENCE OF: I onset to death
<br />in death) I
<br />Sequentially Ust cortMons, If (b) I
<br />a Meadingtotheceusageted DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />on line a.
<br />I
<br />Ender the UNDERLYING CAUSE
<br />(diseeseorin)uryfhatinf8ated (e)
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />LOST
<br />(d) I
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given In PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ❑ NO
<br />y
<br />20. IF FEMALE:
<br />21a. NEROFDEATH
<br />21b. IF TRANSPORTATION INJURY
<br />21c.WASANAUTOPSY PERFORMED?
<br />XNot pregnant within pest year
<br />Sturm ❑ Homicide
<br />❑ Driver/Operator
<br />YES NO
<br />❑
<br />tr
<br />13 Pregnant at time of death
<br />L3 Accident❑ Pending Investigation
<br />❑
<br />Passenger
<br />a
<br />n
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Suicide ❑ Could not be determined
<br />❑ Pedestrian
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />E
<br />13 Notpregnent,butpregnant 43days to1year before death
<br />❑
<br />Other (Specify)
<br />COMPLETE CAUSE OF DEATH?
<br />r
<br />E
<br />❑ Unknown if pregnant within the past year
<br />❑ YES ❑ NO
<br />U
<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.INJURYATWORK?
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO
<br />22t. LOCATION OF INJURY - STREET 8 NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIMEOFDEATH
<br />11 3 O/L' S ko m
<br />-
<br />~
<br />23b.DATE S NED (M~oDY) ° 23c. TIME OFDEATH ~ 24o. PRONOUNCED DEAD (Mo., Day, Yr.) 24d.TIME PRONOUNCED DEAD
<br />"
<br />a
<br />C
<br />m
<br />02:00 P m ~
<br />M
<br />C
<br />C
<br />24e. On the basis of examination and/or Investigation, In my opinion death occurred at
<br />23d. To the beat of my kn rigs, death occurred at the time, date and place
<br />211
<br />i
<br />l
<br />t
<br />e I
<br />and due to the taus tad. natu d Title) ♦ p p the time, date and place and due to the cause(s) stated. (Signature and T
<br />a
<br />oe t~
<br />
<br />26. DIDTOBACCO I1SE CONTRIBUTE THE DFATH?
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />❑ YES 940 ❑ PROBABLY ❑ UNKNOWN
<br />❑ YES 0
<br />Not Applicable If 26a Is NO ❑ YES ❑ NO
<br />27. NAME, TITLE ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Gordon J. Hrnicek, M.D. 729 N u er Ave., Grand Island NE 68803
<br />28a.REGISTRAR'SSIGNATURE
<br />Mal coofk I
<br />28b. DATE FILED BY REGISTRAR (Mo., Day,Yr.)
<br />DEC 13 2nn . s
<br />
|