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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMEAIT OF HEALTH AND FiUMA�!V SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA�ICA, DEp,4kTM�'�Il�" O� AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR iTl i��C L2S3 ..�"�` ,,,
<br />_ �`��;. � a '
<br />DATE OF ISSUANCE �j " �'�3��� �
<br />� ��/` r� - , ,, �
<br />07/18/2011 � 0�. 2 0 815 J � s T a "z� S,, �,C�QPER - e � a��'
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<br />' DEP/`,i�TMEN� OF �EALT�ARIl�� =� -
<br />LINCOLN, NEBRASKA HlJrlkl�l'�E�tVl�'E'�5 ,
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERV�� ES '•�� G�? ; ti�..�•�'`.� '� `'� �`
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<br />1. DECEDENTS•NAME (Flrst, Mlddle, Lasf, SuffDc) 2. SDC �� y.�. DATE dF DEATH (Mo:, Day, Yr.)
<br />James Ronald Worth Male �`'July�9; 2011
<br />4. CITY AND STATE OR TERRITORY, OR POREIGN COUNTRY OF BIRTH Sa. AGE - Last BlRhday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8, DATE OF BIRTH (Mo., Day, Yr.)
<br />(�'�•) MOS. DAYS HOURS MINS.
<br />Broken Bow, Nebraska 70 November 29,1940
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />507 OSH PITAI. � ��aUerrt OTHER � Nursing Home/LTC � Hosplce Factllty
<br />Bb. FACILITY•NAME (IT not Insdtutlon, gNe street and number) � ER/OutpafleM ❑ Decederrt's Home
<br />�
<br />� Saint Francis Mediql Center ❑ ooa ❑ ocnor Ispeciry�
<br />v
<br />� 8c. CITY OR TOWN OF DEATH (Include Zip Code) Bd. COUNTY OF DEATH
<br />e Grand Island 68803 Hall
<br />� ea. RESIDENCESTATE eb. COUNTY 9c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL 9d. STREET AND NUMBER 9e. APT. NO. 9L ZIP CODE 8g. INSIDE CITY LIMRS
<br />� 1109 W 12th S� 68801 � ves ❑ No
<br />� 10p. MARfI'AL STATUS AT TIME OF DEATH � Marrtad � Never Marrled 10b. NAME OF SPOUSE (First, Middle, Laet, Suftbc) If wHe, glve malden rmme
<br />� � ruiamed, but separated ❑ Widowed ❑ oivorcea ❑ un�,own Margie Ann Sole
<br />� 11: FATHER'S•NAME (First, Middle, Last, Suffhc) 12. MOTHER'S-NAME (First, Middle, Maiden Sumame)
<br />m Claude Porter Worth Margaret Simonson
<br />°' 13; EVER IN U.3. ARMED FORCES? Give dates of service If Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />g (ves, No, oruntc.) NO Margie Worth Wife
<br />,� 15. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 78c. DATE (Mo., Day, Yr.)
<br />� ❑ Burial ❑ DonaUon
<br />Not Embalmed July 10, 2011
<br />� Cramatlon 0 EntombmerM, 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />p Removat ❑ Other (Specify)
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Sdeet, City or Town, State) 17b. Zlp Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See Instructlons and exam les
<br />18� IpART I. EMer the chaln oi eve�rte-dlaeasea, InJuries, or compllcationedhat dlrectiy caused the death. DO NOT e�rter tarminal eveMa such ae cardlac aneat, ; APPROXIMATE INTERVAL
<br />� reaplratory arreat, or ventricular flbrlllatlon wlthout ehowing Ne etlotopy. DO NOT ABBREYIATE EMer only one wuae on a Iine. Add additlonal Iines It neceesary.
<br />IMMEDIATE CAUSE: ; onset to death
<br />naeeEOwre cause �Fl� a) Cardiovascular Disease ;> 5
<br />d�sease or condidon resultlng
<br />�� d �� DUE TO, OR AS A CONSEQUENCE OF: : orreet to death
<br />s�,�e�uenY ��s ��awo�, n b) End Stage Renal Disease i> 5
<br />any, leetling to Ne cause Iietetl
<br />on Iine a DUE TO, OR AS A CQNSEQUENCE OF: � o�et to death
<br />F.nterUre UNOERLYING CAUSE �) Dlabetes Mellitus ;> 5 Years
<br />(d�seese or InJury that Inidated
<br />tlje evente resutung In death) DUE TO, OR AS A CONSEQUENCE OF: : otmet to death
<br />"`� d)MRSA Infec�on : > 1year
<br />18: PART II.OTHER SIGNIFlCANT CONDffIONS�Conditlorre wrrtributlng to the death but not resultlng In the urrclerlyt� cause given in PART i. 18. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 216. IF TRANSPORTATION INJUR 27c. WOS AN AUTOPSY PERFORMED?
<br />�
<br />� � NM P�9�t withln Past Yaar � NaNr81 � Homidde � OttVOtlCPerato� � YES � NO
<br />W .� PregneM etdme at daath � Pessen8et
<br />V ❑ AccltlsM � ParMing Inveatigatlon
<br />Q Not pragnaM, but pregnaM within 42 daye af death gulcide Could not be determ�rted � P��" 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />� � Na pre¢nam, bus pree� 4s dara w � rear berore aea�h � ❑ � p�,� �s�qy� TO COMPLETE CAUSE OF DEATH?
<br />� � Unknown it PreBnant wlthln the P� Y� ❑ YES ❑ NO
<br />a 22a. DATE OF INJURY (Mo., Day, Yr.) 2Zb. TIME OF INJURY 22c. PLACE OF INJURY•At home, fartn, atreet, factory, oftice building, construction site, etc. (Specify)
<br />E
<br />s
<br />.0 22d. INJURY AT WORKT ZZe. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />� ❑ ves ❑ No
<br />22(. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. Cff17TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (MO., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />B W July 9, 2011 ���
<br />��� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ��� Y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />$ � o Jul 11, 2011 04:39 AM ��<�
<br />. To the bee! of my knowtedge, death oeeurted at the tlma, date and ptaee �
<br />24e. On the basie at exeMnation anUfw Investigatlon, in my opinion death occurred at
<br />� B and tlue to the cauae(a) atatetl. (Signatura antl TWe) o�$ the time, tlate end plaae end due to the cauae(s) efeted. (SlBnature and Tide)
<br />g Jennifer L Brown, MD ��
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH9 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREDT 26b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN � YES � NO Not Appllpbla H 28a Is NO ❑ YES ❑ NO
<br />27. NAME, TITLE D ADDRE OF CER ER PH SI , HYS IAN ASSI3T T, RO Eii'3 HYS C R ORN (Type or PriM)
<br />Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />262. REGISTRAR'S SIGNATURE �- , � 286. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />July 11, 2011
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