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To Be Completed/Verified by: FUNERAL DIRECTOR 1
<br />1. DECEDENTS-NAME (First, Middle, Last, Suffix) 0 Q ry
<br />John L French 2 0 1 4 8( 0 3
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo.,Day,Yr.)
<br />June 8, 2009
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />.
<br />Spalding, Nebraska
<br />5a. AGE -Last Birthday
<br />513. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />July 11, 1947
<br />(Yrs.)
<br />61
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />506 -60 -7905
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Nebraska Methodist Hospital
<br />8a. PLACE OF DEATH
<br />HOSPITAL: ® Inpatient OTHER;❑ Nursing Home/LTC ❑ Hospice Facility
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />❑ DOA ❑otner(Speeny)
<br />$c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68114
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Platte
<br />9c. CITY OR TOWN
<br />Columbus
<br />9d. STREET AND NUMBER
<br />1714 9th Street
<br />9e. APT. NO.
<br />91. ZIP CODE
<br />68601
<br />9g. INSIDE CITY LIMITS
<br />® Yea ❑ No
<br />10a. MARITAL STATUS AT TIME OF DEATH III Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />106. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Beth Newman
<br />11. FATHER'S -NAME (First, Middle,. ..Last, Suffix) -
<br />James Howard - French I
<br />12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br />Dorothy McManaman
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service U Yes.
<br />(Yes, No, or Unk.) Yes 07/28 1967 - 04/29/1969
<br />14a. INFORMANT -NAME
<br />Beth French
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />Iii Burial ❑Donation
<br />❑ Cremation ❑Entombment
<br />❑ Removal ❑Olher(speciry)
<br />16a. EMBALMER- SIGNATU
<br />\I .L
<br />16b. LICENSE NO.
<br />IAZ (.Q
<br />16c. DATE (Mo., Day, Yr.)
<br />June 12, 2009
<br />16d. CEMETERY, EMATORY OR OTHER LOCATION CITY /TOWN STATE
<br />Columbus Cemetery Columbus Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Gass Haney Funeral Home, 2109 14th Street, Columbus, Nebraska
<br />17b. Zip Code
<br />68601
<br />'
<br />To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events - diseases, Injuries. or complications. that directly caused the death. 00 NOT enter temtinel events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />disease r condition resulting a) T ,'' 1 t 1�
<br />in death) / A [I
<br />r
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Sequentially Ilet conditions, If b)
<br />any, leading to the cause listed
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE c) -.
<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)
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CON ACTED?
<br />❑ YES 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 If pregnant within the past year
<br />21a. MANNER OF DEATH
<br />Jatura, ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21e. WAS AN AUTOP ERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES
<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 sate, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET 8 NUMBER, APT. NO. CITYITOWN STATE ZIP CODE
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<br />a
<br />23a. DATE OF DEATH (Mo., D Yr.)
<br />6/r% /ZGOr
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<br />a
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<br />tb = r
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />236. DATE SIG ED (Ma., Day, Yr.)
<br />& Lyl
<br />23c. TIME OF DEATH
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<br />w `� 1c� m
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />23d. T. e b 1 of my knowledge, death occurred at the time, date and place U W z O
<br />d due o the eause(s) stated. (Signature and Title) - Ili Z 7
<br />c ar 120a
<br />24e. On the basis of examination and/or Investigation, in my opinion death occurred
<br />at the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />4R
<br />25. DID TOBAC t • USE CONTRIBUTE "ill I i i 2 6a. I1.AS ORGAN OR TISSUE DONAI ION BEEN CONSIDERED?
<br />-,
<br />❑ ❑ NO ❑ PROBABLY t 'tJ - NOWN I 26a. YES ❑ NO
<br />2613. WAS CONSENT GRANTED?
<br />i Not Applicable It 26a Is NO ❑ YES WHO
<br />27. ITLE AND ADDRESS � OF / � C ! ERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />� • s�h V. . 60(1c M_3,. 7 82Z DA f' N i t - r 5 77 °NAM t NZ- ( (( y
<br />P
<br />28a. R GISTRAR'S SIGNATURE z
<br />:.
<br />2813. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />l! IN 30 BIN
<br />Date Issued:
<br />JUN 3 0 MA
<br />HA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 335661
<br />NEBRASKA STATE OF OF DEATH
<br />This certifies this document to be a true copy of an original record on file with Vital Statistics, Douglas County
<br />Health Dept., Omaha, Nebraska. Certified copies must have a raised seal in the area to the left. Reproductions
<br />of this green certificate are not legal copies.
<br />Registrar:
<br />AULC: cA4-7-
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