|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF, H�EALTH„At;fG� Mt/MAN, SERVIC�S,- IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA b�PARTMENT^OF HEALTN AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL R��.ORD,S.
<br />,
<br />flATE OF ISSUANCE �����Q�� �� � '
<br />� 012 0 8 8 2 5 STaN�� S COOPER �• �;,
<br />10/09/2012 AS�ISTANT`STATE'R`EGI$Tf�AR� ' "
<br />DEPARTM�NT OF HEALTH AND
<br />LINCOLN, NEBRASKA HUINAl1Y �
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES "•` v'° � '•�, �� �, 12 03707
<br />rGOT�c�rre-r� n� n�eTU . "`f, �' `
<br />--._... .----- -• ----• , _
<br />1. DECEDENTB•NAME (First, Mlddte, Last, SuffUc) 2. SE7C ` a, '�3. DATB OF DEA7H (MO., Day, Yr.)
<br />James Lee Gabel Male _ Octobe� 2, 2012
<br />4. CITY AND 9TATE OR TERRITORY, OR POREIQN COUNTRY OF BIRTH 8a. AGE - Last Birthday b. UNDER 1 YEAR Se. UNDER 7 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(YB•) MOS. DAYS HOURS MINS.
<br />Scottsbluff, Nebraska 58 November 24, 1953
<br />7.,SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />50&78-0472 �� ❑�npaGeM OTHER ❑ Nursing Home/LTC � Hospice Faelitty
<br />Sb. FACILITY•NAME (if ►rot I�Ututton, gNe street ami number) � ERiOutpatleM ❑ DeeedeM e Home
<br />K
<br />� Filimore County Hospital ❑ oon ❑ aher (speciry)
<br />� 8c. CITY OR TOYYN OF DEATH pnclude Zip Code) 8d. COUNTY OF DEATH
<br />c Geneva 68361 Filimore
<br />� 8a, RESIDENCESTATE 8b. COUNTY 8a CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />�7 9d. STREET AND NUMBER e. APT. NO. 8L ZIP CODE 8g. INSIDE CITY LIMITS
<br />� 4208 Pennsyivania Ave 68803 � r�s ❑ No
<br />a 10'a. NWRITAL STATUS AT TIME OF DEATH � Mlarried ❑ Never Married 1�b. NAME OF SPOUSE (Ftrst, Middle, Last, Suftix) H wBe, give malden reme
<br />� ❑ n�maa butseparated ❑ Widowed p oroo�ea ❑ u�� Sandra Strauch
<br />d
<br />� 11, FATHER'S-NAME (First, Middle, Last, SufNx) 12. MOTHER'3-NAME (Flret, Middle, Malden Surmame)
<br />m Raymond Gabel Martha Schoeneman
<br />Q ' 13. EVER IN U.S. ARMED FORCES? Ghre dates of servles H Yea. 14a. INFORAAANT-NAME 74b. RELATIONSFOP TO DECEDENT
<br />E
<br />s �res, No, or unk.) No Sandra Gabel Spouse
<br />,$ 1S. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />� ,� eunai ❑ oo�tlon �urle D. Sheffteld 1397 October 6, 2012
<br />Q CremaUon � EMombmeM 18d. CEMETERY, CREMATORY OR OTHER LOCATION CIT1f / TOWN STATE
<br />0 RemoYai ❑ o�rer �speciry► Grand Island Ciiy Cemetery Grand Istand Nebraska
<br />17a. FUNERAL HOME NAME ANO MAILING ADDRESS (Street, Clty ot Town, State) 17b. Zlp Code
<br />- All Faiths Funeral Home, 2929 S. Locust Street, Grand island, Nebraska 68801
<br />CAUSE OF D H See nstructions and exam les
<br />7& PART L E�rter the chatn o( eveme..dieeaaea, UJudee, or eomplleatiorre-thet elreatly eaueed the death. DO NOT eMer temdnal eveme euch ae eaNiac arrest, ; APPROXIMATE INTERVAL
<br />resplratory arteat, m ventriwlar flbrlltadon withuut ahmring tlre eflotopy. DO NOT ABBREVIATE ENaz onry o�re muee on a Wre. Add additlo�l Wma H�ry.
<br />IMMEDIATE CAUSE: ; ormet to death
<br />�arE cause � e) Massive Head Trauma E Minutes
<br />disease or condtdon r�uftinp
<br />in death) DUE TO, OR AS A CONSEQUENCE OF: : o�reet W death
<br />SequeMlelty IIaS conditlare, H b) Farm Accidant : Minutes
<br />a�ry. leaUlnp m the eauae Iiated
<br />on Une a DUE TO, OR AS A CONSEQUENCE OF: ; o�reet to death
<br />F_nEe�th9 UNDERLYINO CAUSB �) �n Over By Combine : Mlnutes
<br />(disease or InJury that inftlated
<br />��"t ��"e �" �� DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />LAST �
<br />78. PART II.OTHER SIGNIFlCANT CONDITIONS�o�klore conMbuting to the death 6ut not resulUng in the umierlyi� eause given in PART I. 19. WI6S MEDICAL EXAMINER
<br />. OR CORONER CONTACTED9
<br />� ❑ YES � NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 27b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED4
<br />� [] Not DreBnaM wfthln �et Yeaz ❑ n�ar� � Ho�aa. � crnreeo��ro� � ves � No
<br />W � PreBna�rt et tlme oi tleath � Paseen9er
<br />t � � Aedde�R � Pendln8 imestl9adon
<br />� Not pregna�u, but prepnaMwkhln al tlays otdeaN ��� ���d not be determ�netl � PedesMan 27d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />'� ❑ Na v�ea�. � ore¢� 4s uere m� rear eetore deam � � � p�er (speetryl TO COAAPLETE CAUSE OF DEATH?
<br />� � UNmown H P�ee�t wlthin ehe P� Yeaz ❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, Tarm, etreet, factory, offlce building, constructton atte, etc. (Specliy)
<br />8 October 2; 2012 0925 AM Farm Fleld
<br />.S 22d. INJURY AT WORK7 22e. DESCRIBE HOW INJURY OCCURRED
<br />� Head ran over by the Combine
<br />p ves p No
<br />22L LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITYROWN STATE ZIP CODE
<br />816 Road 12, Geneva Nebraska 68361
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIQNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />s October 2, 2012 � �
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH � 24c. PRONOUNCED DEAD (Mo., Day, Yr.J 24d. TIME PRONOUNCED DEAD
<br />� Z October 5, 2012 09:48 AM g�<�'
<br />.� 0 . TO the best at my knowiedpe. death Occurre0 at the tlme. date and Place $(5 �
<br />24e. On Ule basle ot emoL�atlm endlor Im¢atlgatian. in mY eP�n daat6 oecurretl at
<br />� a�M due to Ne muse(e) a�ed. ($19�mture and Title) �@ fhe 11me. d¢te en0 Plaee m�d due M tire muse(s) �. (SlgnaWre mM TIUe)
<br />~$ Jason L Bespalec, MD ~ g a
<br />Z. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS OROAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNIWOWN � YES ❑ NO NotAppliwble H28a Is NO ❑ YES � NO
<br />. IT R R(Type or Prlrn
<br />Jason L Bespalec, MD, 1323 H Street, P.O. Box 268, Geneva, Nebraska, 68361
<br />28a. REGISTRAR'3 SIONATURE �_ � 28b. DATE FlLED BY REGISTRAR (MO., Day, Yr.)
<br />October 5, 2012
<br />
|