|
so
<br />1. DECEDENT'S-NAME (Finn, Middle, Last,
<br />I$
<br />Jeffrey Lynn Fern
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kearney, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />508-56 -0860
<br />lb. FACILITY -NAME (t notlhw2bdlon, give street and number)
<br />Nebraska Medical Center - University
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68198
<br />ga RESIDENCE-STATE
<br />Nebraska
<br />Sd. STREET AND NUMBER
<br />2320 N. Custer Ave.
<br />10a. MARITAL STATUS AT TIME OF DEATH Si Married ❑ Never Married
<br />❑ Marled, but separated 0 Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (Filet, Middle, Last, Suffix)
<br />LaMoyne Fern
<br />13. EVER IN U.S. ARMED FORCES? Give dabs of service if Yes.
<br />(Yes, No. orUNc) No
<br />15. METHOD OF DISPOSITION
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stab)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />1e.. PART I. Eider the OM ofevwo.- Messes, heels., or eempagtlons- that directly soused the death. 00 NOT enter t nnhul events such es eautee West,
<br />mpualory west, orveaNlWar ftbellethan tined shoeing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lose If neoetaary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting a)
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF: ,,/ �1
<br />Sequentially list conditions, H b) /� C / ! , _ 2 11-44../3 C � /Ct i
<br />_ any. leading to the cause teed ,/Y, .✓.�r �.tiiCJ`
<br />on line a.
<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:
<br />LAST
<br />18. PART N. OTHER SIGMFICANT CONDITIONS-Conditions contributing to the death but not resulting b the underling cause given In PART I.
<br />20. IF FEMALE:
<br />❑Not pregnant within post year
<br />OPregnant 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 />❑Wdmann N pregnant %Hain the past year
<br />22a. DATE OF INJURY (tlo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET NUMBER, APT. NO. CITY/TOWN
<br />8 3
<br />°Mel
<br />Ilaemeaon
<br />❑Removal
<br />23b. DATE
<br />25. DID TOBACCOrI,s
<br />laves- -
<br />27. NAME, WPM AND
<br />This certifies
<br />County Heal
<br />Reproduction
<br />❑
<br />D Emamhswnt
<br />O 0thertapedfle
<br />23d. To
<br />and .due to
<br />Date I
<br />d)
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />Suffix
<br />rib. COUNTY
<br />Hall
<br />18a. EMBALMER- SIGNATURE
<br />Not Embalmed
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />22b. TIME OF INJURY
<br />m
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23s. DATE OP CIEATH (M Day, Yr.)
<br />(M9. Yr.4' j ,..
<br />of Any knowl
<br />CERTIFICATE OF DEATH 353881
<br />14a. INFORMANT -NAME
<br />Barbara Fern
<br />tied CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN
<br />Autumn Hills Cremation Services Omaha
<br />( vet ■L h (c Q�
<br />2 /MANNER OF DEATH
<br />.CS.I Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />23e TIME OF DEATH
<br />"t L A m
<br />220. PLACE OF INJURY -At home, Fenn, abut, factory, office building, construction site, etc. (Speaty)
<br />Welkin, date and place
<br />FIER (Type or PrInty ' I . /
<br />ct y talk ,' t l (I/if/
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />60
<br />MOS.
<br />Be. PLACE OF DEATH
<br />M4$E1RU ®inpatient
<br />p ER/Outpatient
<br />❑ DOA
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Barbara Jean Mooney
<br />0 Cofer
<br />.4J
<br />Sb. UNDER 1 YEAR
<br />DAYS
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />Se. APT. NO.
<br />2. SEX
<br />HOURS
<br />lab. UCENSE NO.
<br />TO THEDt?51TH? „ s Sit. HAS ORGAN OR TISSUE ATION BEEN CONSIDERED?
<br />INUKKNUy■n ' l f3'TES -
<br />Male
<br />Sc. UNDER 1 DAY
<br />24a. DATE SIGNED (Mo.. Day, Yr.)
<br />PAINS.
<br />9/0810 Nursing Home/LTC ❑ Hospice Facility
<br />p Decedent's Home
<br />❑ Gd>lfy)
<br />Sd. COUNTY OF DEATH
<br />Dou las
<br />W. ZIP CODE
<br />68803
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Janice.! English
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />3. DATE OF DEATH (Mo.,Oay Yr.)
<br />January 20, 2014
<br />6. DATE of BIRTH (Mo., Day, Yr.)
<br />March 30, 1953
<br />Sg. INSIDE CITY UNITS
<br />Yee No
<br />14b. RELATIONS TO DECEDENT
<br />Wife
<br />166. DATE (Mo., Day, Yr.)
<br />January 23, 2014
<br />STATE
<br />Nebraska
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />w
<br />onset to death
<br />onset to death
<br />onset to death
<br />17b. Zip Code
<br />68801
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ yes ❑ No
<br />21c. WAS AN AUTOPSY
<br />❑ YES NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES 0 N
<br />STATE ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of exmcinaton and/or b eedgatbn, b my opinion death occurred
<br />at the dm., date and place and due to the cause(s) stated. (Signature and Tit.)
<br />25b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES ❑ NO
<br />2a1. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />JAN 2 9 mu
<br />m
<br />'s document to be a true copy of an original record on file with Vital Statistics, Douglas
<br />Dept., Omaha, Nebraska. Certified copies must have a raised seal in the area to the left.
<br />f this green certificate are not legal copies.
<br />e
<br />JAN 2014 Registrar:
<br />a
<br />
|