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1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Wayne R. Forgey
<br />2, SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />June 14, 2009
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ainsworth, Nebraska
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />71
<br />5b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />6. DATE OF 8IRTH (Mo., Day, Yr.)
<br />February 3, 1938
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />507 -48 -4323
<br />8a. PLACE OF DEATH
<br />HOSPITAI; Si Inpatient MR ❑ Nursing HomeA.TC ❑ Hospice Facility
<br />❑ ER/Outpatient ❑Decedent's Home
<br />❑ DDq ❑
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />Rock Co. Hospital
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Bassett 68714
<br />8d. COUNTY OF DEATH
<br />Rock
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />96. COUNTY
<br />Keya Paha
<br />9c. CITY ORTOWN
<br />Springview
<br />94. STREET AND NUMBER
<br />P. 0. Box 268 122 N. Ash
<br />9e. APT. NO
<br />91. ZIP CODE
<br />68778
<br />9g. INSIDE CITY LIMITS
<br />x1 YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH - lit Married ❑ Never Married
<br />❑ Married, but separated 0 Widowed ❑ Divorced ❑ Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Marvel M. McCoy
<br />11. FATHER'S -NAME (First, Middle, Last, Sutflx)
<br />Glenn G. Forgey
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Lona M. Massey
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If yes.
<br />(Yea, no,orunk.) No
<br />14a. INFORMANT -NAME
<br />Marvel Forgey
<br />14 b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />Burial ❑ Donedon
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />tee. E •SIGNAL I.
<br />vYY
<br />16b. LICENSE NO.
<br />1105
<br />16c. DATE (Mo., Day, Yr. )
<br />June 19 19, 2009
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Mt. Hope Cemetery Springview Nebraska
<br />17�,,,F��1�rr k �yy+�r+AME AND ADDRESS (Street, City or Town, Slate) 17b. Zip Code
<br />lll1t:11 AQ
<br />IX 1320. East Fourth AiuswortJ Nebraska 69210
<br />19 PART 1. Enter the 9Daln of events-Alumna, injuries, or complication- that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Inc. l Add additional ens If necessary.
<br />IMMEDIATE CAUSE: onset to death
<br />t C 1
<br />IMMEDIATE CAUSE(F1nal (o) 1 r 1 <
<br />orcon dMon 1 pvitin9 DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />M death)
<br />( C
<br />SequemlNyllet conditions, B 0) r� �� _� 7_ I r I r O %-v.12..0-..-6
<br />lading +'
<br />srry, tbthe aua lilted DUE TO, OR AS A CONS QUENCE OF: ' I death
<br />onsetMd
<br />on Ibis a. 1 1
<br />Ent rtheUNDEMINGCAU8E --
<br />(dlaase orbl)urythat Initiated (o) .! _ 1 " _ d r 1 A , 0 - ,. _ 30
<br />the
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST (d) . - ._ � _ . ♦' - te r - 1
<br />18. PART 8. OTHER SIGNIFICANT CONDITIONS•ConditIona contributing to the • .: t9 but not resulting in the u : rlying cause given In PART I.
<br />1 Onset to death
<br />„
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES L7 NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Nol pregnant, but pregnant within 42 days ofdeath
<br />❑ Not naM, but pregnant 43 ds e b 1
<br />Pre? Y year before death
<br />0 Unknown if pregnant within the past year
<br />21e. MANNER OF DEATH
<br />0 Natural ❑Homicide
<br />❑ Accident❑ Pending Investigation
<br />❑ Suicide ❑Could not be determined
<br />219. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑Pabeenger
<br />❑Pedeatdan
<br />❑Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES WINO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />0 YES 0'N0
<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 />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET &NUMBER, APT NO. CITY/TOWN 600E ZIP CODE
<br />AINO
<br />NVIQISAHd 6 IPwAV
<br />Aq Petatdulogi aq
<br />23a. DATE OF DEATH (Mo., Day, Yr.) / •
<br />� ` `
<br />i
<br />1 24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b.TIME OF DEATH m
<br />23b. r TESIJ3NED (MO.,Day,Yr.)
<br />23c.TIMEOFO
<br />S.
<br />t 133 `�
<br />24c.PRONOUNCED DEAD (Mo., Day,Yr.)
<br />24d.TIMEPRONOUNCEDDEAD
<br />m
<br />aaa
<br />231 To the best of my knowledge, death occurred at the time, date and place 24e. On the bards of examination and/or Investigation,
<br />and du to the causes tat � . (Signature and Title) • s B b the llme, dale and place and due 10 the
<br />r/ / Il F i
<br />In my opinion death occurred at
<br />cause(s) stated, (Signature and Title ) •
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ❑ NO PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />lir YES 0 NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES 1 ' NO
<br />277 NAME, TITLE AND ADD SS OF CERTIFIER (PHYSICIAN, CORONER'SP YSICIANOR COUNTY y AAT { TORNL(TypeorPnnt)
<br />28e REGISTRAR'S SIGNATURE f
<br />Irk* A. ►,
<br />711 C
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JUN 2 5 2009
<br />STATE OF NEBRASKA 204307170
<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 DEPAR oro HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL R5
<br />DATE OF ISSUANCE
<br />OCT 2 6 2012
<br />LINCOLN, NEBRASKA
<br />•
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPOR'O 9 25615
<br />615
<br />CFRTIFICATF AP nFATLI V
<br />HHS-81 11/03 (55081)
<br />
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