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To Be Completed/Verified by: FUN° — "I -°-'
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Forest Willard Scobie
<br />2. SEX
<br />Male
<br />3. DAF D� rJkZRDayrYr.)
<br />August i 2009
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Giltner, Nebraska
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />75
<br />5b. UNDER 1 YEAR
<br />5d, UNDER 1 DAY
<br />6. DATE OF BffiTtfild., Day, Yr.)
<br />Septembe 5, 1933
<br />MOS.
<br />DAYS
<br />HOURS
<br />PAINS.
<br />7. SOCIAL SECURITY NUMBER
<br />508 -38 -1359
<br />8b. FACILITY -NAME (N not Institution, give street and number)
<br />Interstate 80
<br />8a. PLACE OF DEATH
<br />HOSPRALI ❑ Inpatient OTHER: ❑ Nursing Home/LTC ❑ Hoejiice Facitljy
<br />- ❑ ER/Outpatient ❑ Decedent's Home While being
<br />Ei DOA giOther(specif by
<br />amhurAnc nn T
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Milford
<br />8d. COUNTY OF DEATH
<br />Seward
<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 />13 Kuester Lake
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />❑ Yes ® No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wire, give maiden name.
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Lou Ella Thiessen
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Forest Ealem Scobie
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Tola Ilene Shepard
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Lou Ella Scobie
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />Meow Operation
<br />['Cremation ❑Entombment
<br />❑Removal ❑0ffie S city)
<br />16a. EMBA R- SIGNATU
<br />t,(.). J �A t,
<br />16b. LICENSE NO.
<br />y
<br />/ c 9 /
<br />16c. DATE (Mo., Day, Yr.)
<br />August 21, 2009
<br />CEM RY, CREMATORY OR OTHER LOC ON CITY/TOWN STATE
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />1 Zip Code
<br />68801
<br />To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />111. PART 1. Enter the chain of events - diseases, Injuries, or complications -mat directly caused the death. DO NOT enter terminal events such as cardiac 00050 ,
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />,/ 2 /
<br />-� /
<br />i
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additions) lines If necessary.
<br />IMMEDIATE CAUSE (Final
<br />IMMEDIATE USE ��� /// Lc
<br />disease or condition resulting a) 7
<br />In death)
<br />DUE TO, OR AS CONSEQUENCE onset to death
<br />Sequentially list conditions, e b) ( > 4 any, leading to Me shoes listed
<br />4
<br />( /�""
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: l V onset to death
<br />f �
<br />Enter the UNDERLYING CAUSE c) ( 2 V 3
<br />injury
<br />(disease or that initiated
<br />the events resulting In death) DUE TO, OR.AS A CONSEQUENCE OF: on to death
<br />LAST
<br />d)
<br />18. PART IL OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES [;ytfo
<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, art pregnant 43 days to 1 year before death
<br />['Unknown if pregnant within the past year
<br />21a. NER OF DEATH
<br />atural ❑ 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 />21c. WAS AN AUTOPSY ERFORMED?
<br />❑ YES [ NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ' o
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br /># IC
<br />22 . TIME OF INJURY
<br />I l�°,7 m
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />Bickford Cottage Assisted Living
<br />22d. INJURY AT ?
<br />DYES 0
<br />22e. DESCRIBE HOW INJU(OCCURRED
<br />I - /
<br />(
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. ,GITYITO � STATE ZIP CODE
<br />' 2 g'.5' W 0610k 1 e- 1- - [ --%/ 1 O 6,U2.5_
<br />a-
<br />12 (0
<br />E o. z
<br />FO
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />A ugust 17, 2009
<br />Z
<br />a �2
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Au a 19, 2009
<br />23c. TIME OF DEATH
<br />3:3 p m
<br />�+ y O
<br />E N a Z
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />y y 2 -- of my knowledge, death occurred at the time, date and place
<br />m c a • the cause(s) stated. Signature and Title)
<br />2 •
<br />0 W 2 O
<br />2 g3
<br />V 0
<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 />25. TOBACC USE CONTRIBUTE TO THE 0
<br />YES NO ID PROBABLY NKNOWN
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a Is NO ❑ YES gl NO
<br />27 LE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />John A. Wagoner, M.D., 80 N Alpha S ., Grand Island. Nebraska 68803
<br />� \
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />AUG 2 0 2009
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH H VMAN- SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE Q1EBISKA, Af2,4MEALT F WEA& t4 AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY" FOR* : 1, GOIRDS
<br />DATE OF ISSUANCE
<br />OCT 20
<br />LINCOLN, N
<br />2009 x ,dNL
<br />. 1"ANt TA7 REWkSTRAR
<br />A#( H TH 4IVD-
<br />NEBRASKA
<br />H tii�CES - t
<br />_ 1 ! ' . s `
<br />s • y �, rt -
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIG S
<br />/+G DTI CIf'►ATL' AC rh ATIJ '� ! -
<br />201404466
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