|
[ To Be CompletedNerified by: FUNERAL DIRECTOR
<br />1
<br />v as.. 1 •1 IV P'. 1 L. VII VGa•s 1 n
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Walter Vernan Lundy 01302807
<br />2. SEX
<br />Male
<br />- -- +vv
<br />3. DATE OF DEATH (Mo „Day,Yr.)
<br />December 9, 2012
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />, North Kenova. Ohio
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />76
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />May 31,1936
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />236 -56 -6920
<br />8a. PLACE OF DEATH
<br />HOSPITAL: Q Inpatient OTHER: ❑ Nursing Home/LTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Nebraska Medical Center - University
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68198
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />❑ DOA ❑ Other(Specify)
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Alda
<br />9d. STREET AND NUMBER
<br />111 Solar Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68810 _
<br />9g. INSIDE CITY LIMITS
<br />® Yes ❑ No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown'
<br />10b. NAME OF SPOUSE (First, Middle,. Last, Suffix) H wife, give maiden name.
<br />Barbara Lieser
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Sinclair V Lundy
<br />12. MOTHER'S -NAME (First Middle, Maiden Surname)
<br />Rhoda Dickens
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, orUnk.) Yes 03/57 -10/75
<br />14a. INFORMANT -NAME
<br />Barbara Lund
<br />14b. RELATIONSHIP TO DECEDENT
<br />' Spouse
<br />15. METHOD OF DISPOSmON
<br />['Burial ❑Donation
<br />®Cremation ['Entombment
<br />❑Removal ❑othegspedity)
<br />15a. EMBALMER-SIGNATURE ,
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />December 14, 2012
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />Autumn Hills Cremation Services Omaha Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Good Shepherd Funeral Home, 4425 S. 24th St., Omaha, Nebraska
<br />17b. Zip Code
<br />68107
<br />W
<br />IU
<br />LL
<br />F
<br />W
<br />V
<br />a
<br />M +
<br />.
<br />ii
<br />a
<br />E
<br />U
<br />CD
<br />m
<br />O
<br />I-
<br />P 28at
<br />CAUSE OF DEATH (See instructions and examples)
<br />15.
<br />PANT 1. Enter Me chain or events - diseases, Injuries, or compacetions- teat directly caused the death. DO NOT enter terminal everts such as cardiac arrest, APPROXIMATE INTERVAL
<br />respiratory west, or ventricular Dbnlianon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Inc. i Add additional lines if necessary.
<br />IMMEDIATE CAUSE: ,, onset to death
<br />IMMEDIATE CAUSE (Final /^ L /�
<br />disease or condition in death) �C.W o.0
<br />condition resultlg a) f _- _1 _ fo\ t pt' Mess a T r>
<br />DUE TO, OR AS A CONSEQUENCE OF : onset to death
<br />Sequentially Est conditions, I b) p �,S
<br />any, leading to the cause listed ` 1 1 8 Si
<br />on line a
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE c) t SrL RA . 1-2 la.40r]
<br />(disease or injury that initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />LAST
<br />d) 1
<br />18. PART S. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />C - 11 l J
<br />`' 3 Ho f COLNCJL �( SO-49-re. fer.�,lrJ k ,1G, CU �o -y1
<br />Q �
<br />r
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />YES
<br />❑ El, NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unknown I pregnant within the past year
<br />21a. MANNER OF DEATH
<br />Im Natural ❑ Homicide
<br />IN
<br />❑ Accident ❑ Pending Investigation - '
<br />❑ Suicide ❑Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />-
<br />0
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES 56 NO
<br />214. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At home, farm, street factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑VES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET 8. NUMBER, APT. NO. .CITY/TOWN - STATE ZIP CODE
<br />' 01.6
<br />d K
<br />E
<br />c1 Q
<br />a U
<br />O W
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 7 -
<br />q WA', - GDL`
<br />z
<br />a vz
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />1)
<br />/ - 2' , 2-
<br />23c. TIME OF DE m DEATH
<br />/326. G
<br />m } S
<br />aa .,
<br />rn o
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />23d. To the best of my knowledge, the, date and
<br />death °courted at the ti P lace
<br />and due to a cause(s) stated. igna ure and Title)
<br />LE, re r
<br />W z
<br />.Ma 2 =
<br />U O
<br />24e. On the basis of examination and/or investlgafion,
<br />at the time, date and place and due to
<br />in my opinion death occurred
<br />the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO 7 DEATH?
<br />" VES ❑,NO . }{ ❑ UNKNOWN
<br />4 � , Y
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable I26a is NO ❑YES ❑ NO
<br />27. NAME, 13,14, TIQADDRESSOFJ;EFITI R or Print)
<br />/"' 1 1Qr,y. ' ,,ky.. •• W.,. M.D. 984030 Nebraska Medical
<br />REGISTRAR S SI TT i J .aan.rara•
<br />, , -- .1e
<br />•
<br />Center Omaha. NE 68198 -4030
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />DEC 1 3 2012
<br />Date Issued:
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />This certfes this docgnpient to be a true copy of an original record on file with Vital Statistics, Douglas
<br />County Health: Dept:; Omaha, Nebraska. Certified copies must have a raised seal in the area to the left.
<br />Reproduction;gfthis green certificate are not legal copies.
<br />DEC 1. 3 2012 Registrar:
<br />eel
<br />
|