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`,. 1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Dorothy Edna Kinkle
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />February 20, 2006
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Madison, Nebraska
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />79
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />January 2, 1927
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />0045
<br />8a. PLACE OF DEATH
<br />HOSPITAL: oil Inpatient OBER U NursingHome/LTC ❑ Hospice Facility
<br />❑ ER /Outpatient ❑ Decedent's Home
<br />❑ coa Q Other (Specify)
<br />ZOG7 5G 506 -86 -0845
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />St. Francis Medical Center
<br />f *,
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />4010 Greenwood Dr.
<br />9e. APT. NO
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />Je YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH gMarried ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />fob. NAME OF SPOUSE (First, Middle, Last, Su(fix) If wife give maiden name.
<br />Harold J. Kinkle
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Carl (NMI) Anderson
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Ivy Edna Sexton
<br />uc) 13. EVER IN U.S. ARMED FORCES? Give dates of service If yes.
<br />(Yes, no, or unk) • No
<br />14a, INFORMANT -NAME
<br />Harold J. Kinkle
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />15. METHOD OF DISPOSITION
<br />9 � X Burial ❑Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. MBgtMER- SIGNAT E°
<br />!
<br />� • � ��� �? cT
<br />16b. LICENSE NO.
<br />/ Q°3
<br />J 7
<br />16c. DATE (Mo., Day, Yr. )
<br />February 24, 2006
<br />r
<br />16d. EMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlaxn Memorial -Park Cemetery, Grand Island Nebraska
<br />ry r
<br />sn r #
<br />" ss
<br />T .r�Ya
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Kleine Funeral Home, 3213 W North Front
<br />18. PART I. Enter the chain of events-diseases, injuries, or complications- -that directly caused the
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final (a) + �1 1 ‘I' k '
<br />St.,
<br />death. DO NOT
<br />Enter only one
<br />Grand Island, NE
<br />enter terminal events such as cardiac arrest, APPROXIMATE
<br />cause on a line. Add additional lines if necessary.
<br />onset
<br />17b. Zip Code
<br />68803
<br />INTERVAL
<br />to death
<br />t ' '"
<br />,.;
<br />disease or condition resulting DUE TO, OR AS A CO EQUENCE OF:
<br />Mdeath)
<br />Sequentially list conditions, if @) .. -'\ IIV V1CI t ' t
<br />I onset to death
<br />.��1 -,
<br />r(J S ') 1 l -, t ;,�"` r „�j
<br />any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death ' mil
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that Initiated (c) '"1 --('L) 1 (C1..0 LS c A
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />LAST
<br />(d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions coptributing to the d�e ut not resulting in a underlying cause given PART I.
<br />'1� \�-- -- e-SL ... Ct•...0(K.3 \'" CA-C
<br />)
<br />K- � t.C� -.`` �'\ i.���'�'''ii� .� 1� ✓` - n ���D'Y^.Gi.p., 5...,. -
<br />., �3 .l,
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES MO
<br />20. IF FEMALE:
<br />yt
<br />year pregnant within past
<br />" a ❑ Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH.
<br />Xetural ❑ Homicide
<br />❑ Accident❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined.
<br />21bIF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES L" NO
<br />/ «
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />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 />y, vk ❑ YES ❑ NO
<br />k " Myr-
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN SINE ZIP CODE
<br />a
<br />, a
<br />o mo
<br />E
<br />.o m
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 20, 200
<br />Z
<br />A.8`1'
<br />_ �
<br />E . era
<br />. w Z
<br />.8 p u
<br />24a. DATE SIGNED (Ms., Day, Yr.)
<br />24b.TIME OF DEATH
<br />m '
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />244. TIME PRONOUNCED DEAD
<br />m
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />February 22, 2006
<br />23c.TIME OF DEATH
<br />21:35 En
<br />24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br />t time, date and place and due to the cause(s) stated. (Signature and Title ) •
<br />23d. To the best of my knowledge, death occur ed at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title ) •
<br />25. DID TOBACCO USE CONTRIBUTETOTHE DEATH?
<br />❑ YES NO ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUES DONATION BEEN CONSIDERED?
<br />❑ YES 0
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES ❑ NO
<br />�! t 27. NAME, TIT AN ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY A ORNEY) (Type or Print
<br />William J Landis, M.D., 2444 W Faidley Ave, Grand Isand NE 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />/SON* A
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />FEB 2 4 2006
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE_ORIGINAL, RECORD. ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT407C5S.�EATIOr WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />MAR 0 7 2006
<br />LINCOLN, NEBRASKA
<br />20/309490
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT 0 , 2 1 Q C
<br />CERT IFICATE OF DEATH j V V �J
<br />= 1ANLEY S CQ6PER
<br />ASST ANT- VTATEPEGISTRAR
<br />HE ALTH AND HUMAN RWCES
<br />
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