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1. DECEDENT'S -NAME (First, Middle, Suffix) le, Last, Sux)
<br />Fred Conner Becker
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo.,Day,Yr.)
<br />January 11, 2015
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Burwell, Nebraska
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />91
<br />5b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Dry, Yr.)
<br />August 19, 1923
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />506 -28 -9841
<br />8a. PLACE OF DEATH
<br />HQSPL79L: 0 Inpatient QI11E6: ❑ Nursing Home/LTC 0 Hospice Faati fy
<br />❑ ERIOUtpadent ❑ Decedent's Home
<br />0 DOA ❑Oth.r(speelfy)
<br />8b. FACILITY -NAME (I not Institution, give street and number)
<br />CHI Health St. Francis
<br />8e. CITY OR TOWN OF DEATH (include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE 9b. COUNTY
<br />Nebraska / Hall
<br />9c. CRY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER 9e. APT. NO.
<br />2627 West 1st T
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® Yea ❑ No
<br />10a. MARITAL STATUS AT TIME OF DEATH RI Martied ❑ Never Married
<br />nknon
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ U w
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) I wife, give maiden name.
<br />Emily E Schneider
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Jesse Nelson Becker
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Mable Conner
<br />13. EVER IN U.S. ARMED FORCES? Give dates of senile. if Yes.
<br />(Yea, No, or Unit.) Yes Q8 /19 /1945 - 0310 1946
<br />14a. INFORMANT-NAME
<br />Emily E Becker
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />ITS) Burial ❑Donation -
<br />re
<br />❑ Cmatlon ❑EOrombment
<br />❑ R an OVal ❑015eria
<br />. .}BEE ALMER- SIGNATURE
<br />- ---
<br />I ' * -
<br />16b. LICENSE NO.
<br />1/,,++i1 j�.
<br />. 02.
<br />FY! 7 _
<br />18c. DATE (Mo., Day, Yr.)
<br />January i6, 2015
<br />1--
<br />16d. CEM TERY, CREMAjjjjjj!!!!llppppppRY OR OTHER LOCATION CITY/TOWN STATE
<br />Cottonwood Cemetery Burwell Nebraska
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Hitchcock Funeral Home, Inc., 212 Grand Avenue, PO Box 871, Burwell, Nebraska
<br />17b. Zip Code
<br />68823
<br />CAUSE OF DEATH (See Instructions and examples)
<br />10. PART I. Enter * 05 af
<br />M .50 evenu - diseases, In)unes, or oamPlIcalions - M W at deec ceased dm death. 00 NOT ether terminal swats such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />onset to
<br />f r1 / / •?
<br />respiratory arrest, or ventricular abrwation without showing tin .5obgy. 00 NOT ABBREVIATE. Ems only ans ears* on • em. Add additional Inn. It ...my.
<br />IMMEDIATE Cp( / ���r ,,
<br />disease or condition. resulting a) G C e- ' L�•.'f
<br />IMMEDIATE CAUSE (Final /f / _v / � ®/J ��;t�Li'��'!/� C..C.�
<br />in death) 'TV"
<br />DUE TO, OR AS A �CON�SrEQUUEEENNCE OF. , /-/ /4-fecyrni.,_, onset to death
<br />s If C Sequentially o the cause I t conditions, a b) ��� \ l , y ! s 1'\ / 2 / 2,40 //y any, leading to
<br />on ens 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 II. 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 ❑ NO
<br />20. IF FEMALE:
<br />OWE 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 betas death
<br />❑Unknown If pregnant within the past year
<br />21a. MANNER OF DEATH
<br />�laturel ❑ Homicide
<br />1:1 Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />IO
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other ($goofy)
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑ YES
<br />21d. WERE TO COMMPP LETE CAUSE FINDINGS GB AVAILABLE
<br />OF DEATH?
<br />❑ YES 0 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 />❑ YES Om
<br />22s. DESCRIBE MOW INJURY OCCURRED
<br />225. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, YE)
<br />o"w January 11, 2015
<br />1
<br />I A g i
<br />y{, F O
<br />Etn < J
<br />'
<br />8 W
<br />0
<br />.8 Z 0
<br />O V
<br />u d
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />2415. 1150E OF DEATH
<br />m
<br />iii: J 23b. DATES NED (M ., Day, Yr.)
<br />oW i is/ lS.
<br />23c. TIME OP DEATH
<br />0820 A m
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />bid. TIME PRONOUNCED DEAD
<br />m
<br />o 23d. To 150 knowledge, dea occurred at the
<br />0 W i a nd d ths ue . e - we(s) et. . (Signature li tie)
<br />1-
<br />A.L. A
<br />time, date and place
<br />`
<br />AAA I
<br />24e. On e basis of examination and/or Investigation, In my opinion death occurred
<br />th
<br />at the time, date and place and due to the cause(.) stated. (Signature and T1tie)
<br />28. DID TOBACCO US CONTRIBUTE TO THE DEATH?
<br />❑ YES t t / ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ' RGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ A K NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable X 26a Is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />John D. Goering MD 820 N. Alpha St., Grand Island, Nebraska 68803
<br />28a. REGISTRAR'S SIGNATURE [[
<br />Aft** �Q
<br />28b. DATE FILED BY REGISTRAR (500., Day, Yr.)
<br />JAN 3 0 2015
<br />P
<br />DATE OF ISSUANCE
<br />02/03/2015
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />201501920
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALthL,4LV' N SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRG'SKA OFHEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY Fag VITAL PECQRb.§. i, 11.
<br />t .1
<br />S.TA7VLEY S, COOPER '
<br />SsIS7N1','T E EGIS7
<br />DEPARTMENT 40 ALTM t 4 ,
<br />P(CIMAN SERVICES r
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICt f'1 07
<br />G O F DEATH b V
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