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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, 1T CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE I �/��a�� �E� • �'_ " -
<br />JUN ��---�-A09 - � ASSISTANT S A� E REGISTRAR _
<br />a�a_9o� �.--
<br />DEPARTMENT OF HEALTH AND
<br />LINCOLN, NFBRASKA HUMAN SERVICES
<br />3TATE OF NEBRASKA- DEPARTMENT OF HEALTH AIVD HUMAN SERVICES FINANCE AND SUPPOR'�1 � ��. ��E �
<br />CERTIFICATE OF DEATH � `� � `�"`�-� `'�
<br />�`�` 1.-DECEDENT'S•NAME (Firet, Mlddle, Leat. &uHla) 2.SEX 3.DATEOFDEATH(Mo.,Dey,Yr.)
<br />���. Wayne R: Forgey Male June 14, 2009
<br />%'r �'• 4. CITY AND STATE OR TERRITORY, OR FOREION COUNTpY OF BIRTH 6e. AOE-Laet Birthdey 6b. UNDER 1 YEAR 6c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Dey, Yr.)
<br />� £;'
<br />(Y�s.) M09. DAYB HOURB MINS.
<br />��-ry`, Ainsworth, Nebraska 71 February 3, 1938
<br />� 7. SOCIAL SECURITY NUA9BER Ba PLACE OF DF.AT}I
<br />�::; 507-48-4323
<br />HOSPITAL• � Inpatient . � ❑ NureingHomelLTC ❑HosplceFecllity
<br />�;° Bb. FACILITY-NAME Qf not InetltuNon, give street nnd number) ❑ ER/OutpeUeM ❑ Decedem'eHOme
<br />�"-
<br />;, �,':
<br />,s�;;' Rock Co. Hospital ❑ ma oane��s�ary�
<br />'' � Bc. CITY OR TOWN OF DEATH pnclude ZIp Code) 8d. COUNTY OF DEATH
<br />f �.
<br />_� Bassett 68714 Rock
<br />; 9a.RESIDENCE-STATE 8b.00UNTY Bc.CffYORTOWN
<br />;;:°� `�, Nebraska Keqa Paha Springview
<br />:�?�> Bd. STREETANDNUMBER 8e. APT. NO 81. ZIP CODE 9g. INSIDE CITY LIMIT9
<br />P. 0. Box 268 122 N. Ash 68778 �I YES ❑ No
<br />�;n 10a. MARRAL &TATUB ATTIME OF DEATH [�Merrled ❑ Nerer Mertied 10b. NAME OF SPOU9E (Flret, Middle, Last, 8uflix) II wile, gWe melden name.
<br />; r��t ❑ Merried, but separated O Widoved ❑ Dhrorced ❑ Unknown
<br />°�E3F Marvel M. McCoy
<br />w��'`r,
<br />� 11. FATHER'8•NAME (Flret, Mlddle, Laet, Sultlx) 12. MOTHER'9-NAME (Flret, Mlddle, Malden Sumeme)
<br />�:' Glenn G. Forgey Lona M. Massey
<br />�-,
<br />?,;'�, h ' 73. EVER IN U.S. ARMED FORCES9 �He detea of aerv�e Hyes. 14e.INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />���%`
<br />� �r�, �o, a� ���.) No Marvel For e Wif e
<br />� 16. METHOD OF DISP081170N 18a. EM8Al5� ""� 1�. LICENSE N0. 18C. DATE (MO.� Dfly� Yr. )
<br />: � Budel ❑ Donedon � � 1105 Juae 19 , 2009
<br />x °�`' OCrematlon ❑EMombment ��•CEMEfERY,CREMATORYOROTHERLOCATION CITY/TOWN 9TATE
<br />�,� ❑ Removal ❑ Other (SpacBy)
<br />r:M,.v,y
<br />�-.. Mt. Hope Cemetery Springview Nebraska
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<br />�� �� 1 U NAME AND MAlLINO ADDRES9 (Stree6 Ciry orTawn, Steta) 17b. Zip Code
<br />���; ���.HO �
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<br />u�.��. 1320. Tast Fourth Ain,swprtk�, Nebrask� 69210
<br />i 6 . ,��i"s u`. '�,.s �� � �.. �� #1�(S8B'�ti�:�CtiCC�G'A'�`$(1d9X$1kt�Ff�.'-:.m�,`;'�e� , v
<br />' JkFJu�£ fiY , A�' ,�",
<br />n'-���: 18. PART I. Enter the chain ot eveirts--diseaseg, InJurles, or ComptlCetlons-Ihat dUeclly caused the death. 00 NOT enter terminel eyont.^, such es caMlea [+rreat, APPROXIMATE INTERVAL
<br />I
<br />,�y"; reaplretory erres� ar verrtricular ttbrIDadon without ehowing fhe e8otogy. DO NOT ABBREVIATE. Emer only one ceuae an a Iine. Add addiGonel Ones If neceseary. i
<br />IMMEDIATECAUSE � onsettotleath
<br />� f � I
<br />' C�� Ib1E9EDfATECAIBE(Rnsl � . i� <
<br />�N�'�`ti �oT���B OUETO,ORA3ACONSE�UENCEOk i anaetrodeeth
<br />,,�". Indeelh) ( C , I
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<br />r�--��� Seque�tlaDYAet�rondltlOne,M ro) � � � �, �
<br />y� � �'��� DUETO,ORA9ACON5 �UENCEOF: I onsettodeath
<br />3 annirea �
<br />xv,.�,� r�ern�eun�.,v�m� � ' 3 �
<br />�k;f (dmeaeemtnJuryUmtwUated ��� -
<br />�'�� DUE T0, OR ASA CONSEOUENCE OF:
<br />ir°y � �����) w i onaetrodea[b
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<br />� 18. PART II.OTHER SIONIFICANT CONDITION&Condidona contrWUllng to tha ath Iwt nW resulting In the u erlying ceuee givan In pART I. 18. WAS MEDICAL EXAMINER
<br />�e� OR CORONER CONTACTEDT
<br />'- zF�;
<br />0 YES L'PI NO
<br />.?,'��i''i 20.IFFEMALE: 27a.MANNEROFDEATH 21b.IFTRAN3PORTATIONINJURY 21aWA8ANAUTOPBYPERFORMED7
<br />� ❑ Not pregnem wlthin pest year 0 Netural O Homidde ❑ DrivedOpereWr
<br />8 ❑ YES GYNO
<br />� � ❑ Pregnent et t6ne o1 death ❑ Accldent0 Pending Invastlga8on O Passen er
<br />� ' °� ❑ Pedestrien
<br />t , ❑ Nolpregnant,butpregnentwithln42deysafdeath
<br />21d. WEREAUTOP9YFINDWOSAVAILABLETO
<br />�. 0 Sulcida ❑ Could not be determined
<br />j ❑ �P�B��butPreBnerrt43deys0otyearbetoredeath ❑Other(Specfy) �pMpLElECAUSEOFOEATH?
<br />�;� � ❑ Unlmown If pregnent within the pestyear ❑ VES G3'NO
<br />4�`; 22a. DATE OF INJURY (Mo., Deg Yr.) 22b. TIME OF INJUPY 22c. PLACE OF INJURY At home, ferm, street, tectory, ottice butlding, conaUUation eite, etc. (Specliy)
<br />??:p� ' m
<br />�.�;; �d.INJURYATWORK? 22e.DE8CRIBEHOWINJURYOCCURRED - � - -� -- " - - �- -
<br />�'°� ❑ YE9 ❑ NO .
<br />�,;
<br />. 22tLOCATIONOFINJUHY-6TREET&NUMBER,APT.NO. CIiY/fOWN 6DRE ZIPCODE
<br />�� ; 23a.DATEOFDEATH (Ma,Oay,Yr.) 24e.DATESIONED (Mo.,Day,Yr.) 24b.17ME0FDEATH
<br />t � : �� /� / ��� m
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<br />x �,. ��� 23b.�TE� NED (Mo.,;Day,YrJ 2�i, m ��� 24c.pRONOUNCEDDEAD(MO.,Dey,Yc) 24d.TIMEPRONOUNCEDDEAD
<br />; o � \ 13 Ci � � , m
<br />�:^ 23d.To the best of my knowledge, death occurted et the tlme, dete arM place � u� �� 24e. On the basis of exemNaUon end/or ImeatlgeUOn, M my opinfan death occunetl el
<br />r� end d ro the cauae(s te .(Signature end Title )♦ � o the tlme, dete and p�aca and due ta the cauae(e) ateted. (9ignature and T(Ue )♦
<br />h4',) F � � * FRCI
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<br />"��'r 25.DIDTOBACCOUSECONTRIBUTETOTHEDEATHT 2Be,HASOR�ANORTI3SUEDONATI0N8EENCON9IDEREDT 28b.WASCONSENTaRANTED7
<br />�,x "._
<br />�7 `; �,/
<br />'` '� 0 YE8 ❑ NO ya PROBABLY ❑ UNKNOWN CtY YE8 ❑ NO Not Appllceble if 28e ie NO ❑ YE9 '� NO
<br />' u 27NAME,TITLEANDADD 3SOFCERTIFIER(PHV3ICIAN,CORON SP 81CIANORCOUNTYATTORNE`�! (7ypeorPrint)
<br />' ; � `l . � � S rt1.,. `Z `�Y e� e�N � �
<br />28a. REOISTRAR'3 SI�NhTURE 28b. DATE FILED BY REQIBTRAR (Mo., Oay, Yr.�
<br />JUN � b 2009
<br />�1
<br />HHS-Bt 11/03(55081)
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