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STATE OF NEBRASKA '� � � � � �'�'�'{�
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTI��D'HUJ�1� �N �-S�RVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAST�'A. ��i41R'j"�11�T O��EALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQR, �IT�kL` I?E �' �� ���
<br />�c`� � . .�
<br />DATE OF ISSUANCE , �.►. ��,����'' /
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<br />S�'�I��Y S�C�PEIR �,. . �„ ,
<br />07/11/2012 A15Sd�T�IN7,�T�E��TR.ZIf�v '�
<br />i3 �.TMEMT QF:HE/�LTH'AIITL�W �"
<br />LINCOLN, NEBRASKA H�MA�I,SER,�VICES ���,,, �,;,� �„�
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVI�F�S�+ '�e R P�,� ;�' "�' �� n
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<br />VCRI Ir1�rAI G Vr LJCNI ll " . � ' • ,/ 1 �u q - b - •�°• . �
<br />1. ECEDENT'3•NAME (Firaf, Mtddle, Last, SufFlz) 2. SIX °'� �S �. DATE O�F Q�A�H (Mo., Day, Yr.)
<br />James Allen Gleason Male ` Det:ember 1, 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last BlRhday b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y�•) MOS. DAYS HOURS MINS.
<br />Omaha, Nebraska 86 November 20, 1924
<br />7. SOCIAL SECURITY NUMBER Sa. PLACE OF DEATH
<br />50&14 HOSPITAL � InpaUertt OTHER ❑ Nuraing HomeILTC � Hosplce Faclllty
<br />Bb„ FACILITY-NAME (If not Instlh�tlon, glve street and monbar) � ER/OutpatleM ❑ DecedenPa Home
<br />�
<br />� Saint Francis Medical Center ❑ DOA ❑ otner (specity>
<br />� Bc. CITY OR TOWN OF DEATH (irrclude tip Code) 8d. COUN7Y OF DEATH
<br />'c Grand Island 68803 Hall
<br />� 8a; RESIDENCESTATE 8b. COUNTY 9c. CITY OR TOWN
<br />w ,Nebraska Hall Grand Island
<br />LL 9d. STREET AND NUMBER e. APT. NO. 9t. ZIP CODE 9g. INSIDE CITY LIMRS
<br />1428 Howard Place 68803 � res ❑ No
<br />$ 108. MARITAL STATUS AT TIME OF DEATH � Marrled ❑ Nevaz Marrled 10b. NAME OF SPOUSE (Flrst, Mlddle, Last, Suffix) ti wHe, give matden rtame
<br />� ❑ e�►nea. b�n $apa�cea ❑ wnaowaa ❑ Divoreed ❑ Unknown Betty L Adams
<br />� 11. FATHER'S-NAME (Firat, Mlddle, Last, Suft6c) 72. MOTHER'S-NAME (Flrst, Middle, Maiden Sumame)
<br />� James Patrick Gleason Edith Kranlz
<br />°' 13; EVER IN US. ARMED FORCEST Oive dates of service tf Yes. 14a. INFORMANT-NAME 74b. RELATIONSHIP TO DECEDENT
<br />$ (vea, No, or unk.) Yes 1942-1945 Betty L Gleason Wife
<br />,$ 75, METHOD QF DISPOSITION 78a. EMBALMERSI(iNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />� ❑ Burlal � Do�Uon
<br />Paul Becker 1085 December 2, 2010
<br />❑ Crematlon � Entombment �8d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />p Removal ❑ otner (speciry� Nebraska Matomical Board Omaha Nebraska
<br />17a• FUNERAL HOME NAME AND MAILING ADDRESS (Street, Cily or Town, State) 17b. Zlp Code
<br />DeWitt Funeral & CremaUon Service, Inc., 1247 N. Burlington Ave, HasUngs, Nebraska for 68901
<br />Nebraska Matomical Board 986395 Nebraska Medical Center Omaha Nebraska 68198-6395
<br />CAUSE OF DEATH See Instructions and exam les
<br />1&, PART I. Frrierthe chain oT eveMS-�dtseasee, iryurlee, or complicatlons-U�at directly caueetl the death. DO N0T e�rter terminal eve� euch aa cardlac arrest, ; APPROXIMATE INTERVAL
<br />reapira[ory erteat, nr verrtrtwlar Nbrillatlon without ehowl� flre edology. DO NOT ABBHEVIATE EMer only orre cause on a IUe. Add adtlWonal 16ree fl�.
<br />IMMEDIATE CAUSE: � o�et W death
<br />u�eemu� causE �� e) Respiratory Failure ;< 1 Week
<br />aiaease w �onamo� resnw�¢
<br />�" �'� DUE TO, OR AS A CONSEQUENCE OF: p onaet to death
<br />Seque�rtially Ilet condido�re, H b) Pseudomonas Pneumonla �< 1 Week
<br />etry. leading ta the cauae Ilated
<br />i
<br />on nne e. DUE TO, OR AS A CONSEQUENCE OF: � o�et to death
<br />Ente�the UNDERLYWO CAUSE �) Chronic Obsiructive Pulmonary Disease ;> 1 Year
<br />(dlaease or InJury that Initlated '
<br />��"�'�"�" �" �'� DUE TO, OR AS A CONSEQUENCE OF: : orreet to death
<br />`^� d)Acute On Chronic Kidney Disease E< 1 Week
<br />78; PART II.OTHER SIGNIFlCANT CONDRIONS-Conditio� contrlbutlng to the death but not reaulUng In the umleriying cause ghren In PART I. 18. WAS MEDICAL EXAMINER
<br />Atrial Fibrilia8on, Congestive HeaR Feilure oR CoRONER CoNTACTED�
<br />� ❑ YE9 � NO
<br />� 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMEDI
<br />� Q Noe PBe�•rmm� P� rear � Natural p HoMdae ❑ onvedoperaror � vES � NO
<br />V ��� �� m d � � AccltleM � PenA�ng Inveatlpadon ❑����
<br />� � Not pregnant, but preg�mnt within 42 daye ot death � Pedeatrlan 21 d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />'� � Not pregnant, but D�eg�nt 49 daye t01 yee� befOre death ❑ smc�ae � Could not be AelermUred ❑�(8�1 TO COMPLETE CAUSE OF DEATH4
<br />� ❑ UMmown H pregnant within the paet Year ❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) ZZb. TIME OF INJURY 22e. PLACE OF INJURY•At home, Tarm, atreeR faetory, oftice building, eonstruetlon ake, etc. (Speci(y)
<br />s
<br />� 22d. INJURYAT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />� ❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIONED (Mo., Day, Yr.) __ 24b. TIME OF DEATH
<br />b� � December 1, 2010 � �
<br />�� Y 23b. DATE SIGNED (Mo., Day, Yr.� 23c. TIME OF DEATH �� k 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />E � Z December 23, 2010 02:13 AM � d<�
<br />$� � 3d. To fhe best o( my Imowledge, death occurted et fhe tlme. tlate end place $ ��
<br />24e. On Ure baele M exeminatlon anNOr imestlgatlon, ln my opinlon tleath xcurrad et
<br />�- mttl due to tlre cause(e) elated. (Sipnature arM Tttle) � � fhe dme. tlate antl place and Aue to the cause(e) afated. (SlpnaW re antl T(fle)
<br />~ � Jennifer L. Brown, MD ~ � $
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED7
<br />❑ YES ❑ NO ❑ PROBABLY � UNIaIOWN ❑ YES � NO NotApplicable H28a ia NO ❑ YES ❑ NO
<br />2. D R I R Y I R ER UNTY A ype or Print)
<br />Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE �+ 2Hb. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 23, 2010
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