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STATE OF NEBRASKA
<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 DEP}IR7�!}E]V C O� HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITA� R�CpI�D ,;," 1 r �
<br />DATE OF ISSUANCE ��/�� � "' . ±9
<br />08/07/2012 sTaive�; s. Co���, ; �', �
<br />� 012 0 7 6�� ASSIST/TNT,S�.��TF R�G.I57RAf�;r, ;.'
<br />DEPARTG�IENT a0�°tiFi4L7'� ANtl " � �
<br />LINCOLN, NEBRASKA HUMAl11$ERI!]'CES � ;.� -
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE$? '-, ,,,�+�� �>, n � u` 19 f19750
<br />CERTIFICATE OF DEATH •-��� '-`�"?;`� .r_ �' -' �� . � "- --� --
<br />1. DECEDENT'3-NAME (Flrst, Mlddte, Last, Sufff�c) 2. SDC '` 3.'DATE'OF DEATH (AAo., Day, Yr.)
<br />James Frank Cochnar Male �. �July 19, 2012�
<br />A. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last BlRhday b. UNDER 1 YEAR Sc. UNDBR 1 DAY B. DATE OF BIRTH (Mo., Day, Yr.)
<br />(YB•) MOS. DAYS HOURS IV�NS.
<br />Dodge, Nebraska 80 February 21, 1932
<br />T. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />507 HOSPRAL � Irtparient TO HER ❑ Nursl� HomeILTC � Hosptce Faetltty
<br />86. FACILITY•NAME (I( rrot Ir�stitudon, give atreet aml rtum6er) � ER/OutpatleM ❑ DecederA's Home
<br />K
<br />� Saint Francts Medical Center ❑ oon ❑ ocr�er�spee�ry�
<br />�
<br />� Sc. CITY OR TOWRI OF DEATM (Include Zip Codey 8d. CWNTY OF D�1TH
<br />c Grand Island 68803 Hall
<br />� 9a. RESIDENCESTATE 8b. COUNTY 8c. CITY OR TO1NN
<br />w Nebraska Hall Grand Island
<br />7 8d. STREET AND NUMBER e. APT. NO. 8f. LP CODE 8g. INSIDE CITY LIMITS
<br />; 517 W 5th Street 68801 ��s ❑ No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH � Married ❑ Never Marrled 10b. NAME OF SPOUSE (First, Middle, Last, Suflbc) If wtie, B�e ma�den rnma
<br />� ❑ nnamea, nu� separarea ❑ vu�aowea p onrorcea ❑ unknown Anna Mae Carkoskt
<br />m
<br />� 11. FATHER'S-NAME (Firat, Npddle, Last, Suffiz) 72. MOTHER'S-NAME (Flrst, Middle, Malden Sumame)
<br />James Joseph Cochnar Anna Maggle Musil
<br />E 13. EVER IN U.S. ARMED FORCES? Give dates oi servlee If Yes. ' 14a. INFORN44NT•NAME 14b. RELATIONSMP TO DECEDENT
<br />$ �r�, No, or unk.► Yes 10/30/1951 Anna Mae Cochnar Spouse
<br />,$ 15. MEfHOD OF DISPOSI770N 16a. EMBALMERSIGNATURE 18b. LICENSE NO. 78c. DATE (Mo., Day, Yr.)
<br />F Q aur�al ❑ Do�mtlon Kevin WoOd 1325 July 19, 2012
<br />❑ CremaUon Q EMombme�rt 18d. CEMETERY, CREMATORY OR OTHER LOCATION CIT'Y I TOWN STATE
<br />❑ Removai ❑ Ottrer (Spec(fy) W��awn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND NWLING ADDRESS (Street, Clty ar Town, State) 17b. Zip Code
<br />Livingston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 68803
<br />C USE OF D TH See instruct ons and exam les
<br />18. PART L EMer the shaln oi ave�rte-dleeasea, InJuriBS, or complicatlonadhat dlrecdy cauaed the death. DO NOT e�rter terminat eveMe euefi as cardlac arreat, ; APPROXIMATE INTERVAI.
<br />reepiratary arrest, or ve�rtricular flbrlUadon wtthout ahowin0 the eHology. DO NOT ABBREVIATE. Frrtaz onry oire wuse on e Wre. Ad0 additlonal 11nee B�.
<br />�rt
<br />IMMEDIATE CAUSE: � oneet to death
<br />�IAMEDIATE CAUSE (Fl�1 a) Severe Stroke E 3 Days
<br />dl�ase or condtllon reeuW�
<br />� d �� DUE T0, OR AS A CONSEQUENCE OF: ; orreet to death
<br />s�,�m�n ��s ��awo�, rc b) Diffuse Vascular Disease E Years
<br />�airyr, leading to the causa Iisted
<br />on IUre a DUE TO, OR AS A CONSEQUENCE OF: � otreet to death
<br />Frrter the UNDERLYIN6 CAUSE C)
<br />(dlsease a InJwy that Initlated -
<br />ure 8"8"te res"re"e m ae�1'� DUE TO, OR AS A CONSEQUENCE OF: 7 o�reet to death
<br />LAST �
<br />� i
<br />18. PART II.OTHER SIGNIFlCANT CONDffI0N9�oMltio� conbibutlng to the death but not resulU� In the undertying cause gfven in PART I. 18. WAS MEDICAL EXAl1�ONER
<br />OR CORONER CONTACTEDT
<br />� ❑ YES Q NO
<br />W D. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />� �❑ NM Pre9naMwithtn D�Y� � NaWral � HomlUtle � DrivaAOPerator � YES � NO
<br />� � r���e �s n� or a�n, � a�ae�s � PemIInB ImaetlBation ❑ P�"g�
<br />a � Nat pregna�rt, but Prepnant wtthln 42 daye oT death gWclde Coum not be determineo ❑���� 21d. VYERE AUTOPSY FINDING5 AVAILABL
<br />� Not prepnaM, but pregnant 49 daye to 1 year before death � � � p�� (gp�y� TO COMPLETE CAUSE OF DEATH4
<br />� .❑ Untmown N P�Bnant wiridn the P� Y�' � ❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY T2c. PLACE OF INJURY-At home, farm, street, faetory, oftlee butlding, cor�struction sRe, etc. (Speciry)
<br />$
<br />.� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />b' � JUIy'f9,10'fZ - - - - a � � - --
<br />�� � 23b. DATE SIGNED (Mo., Oay, Yr.) 23c. TIME OF DEATH ���} 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� Jul 31,2012 12:40PM E da�
<br />� � . To the beat M m�l biowledpe� deBU� occurred aS the tlme� date and place $��� 24e. On the hads oT examinadon and/a ImesdB�on. In my opinlon deaN oecurrad at
<br />�� e�a aue w ure ��� smma. esign�ro ana rnin) ��$ ene n�� a�ee a�w v�e a� aue w we ca�ta) smma. �sm�ewre ana rwe�
<br />'" Richard Fruehling, MD ~ g �
<br />25. DID TOBACCO USE CONTWBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Appllpbla B 28a la NO ❑ YES ❑ NO
<br />27. D RE F R ype or Prlrrt
<br />Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIONATURE �- 28b. pATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />- - August 1, 2012
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