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4•01G111a 11'11i►AeG W t - '•I•
<br />. 1. DECEDENTS -NAME (First, Middle, Last, Sums)
<br />Pauline Angela James
<br />2. SEX
<br />Female
<br />- -
<br />3. DATE OF DEATH (Mo•,Day.Yr.)
<br />December 7, 2014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Spalding, Nebraska
<br />65 AGE•Last Birthday
<br />(Yrs.)
<br />95
<br />2D. UNDER 1 YEAR
<br />8c. UNDER 1 DAY
<br />8. DATE OF BIRTH (Mo., ay, Yr.)
<br />October 28, 1919
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />505 -16 -3876
<br />Ss. PLACE OF DEATH
<br />HOEP(TAL: ❑ Inpat1nt Mina Nursing Home/LTC ❑Hospice Facility
<br />❑ ERtOutpadant ❑ Decedents Hon..
<br />❑ 00* ❑ omeo ty)
<br />lib. FACIUTY -NAME (I not Institution, give street end number)
<br />Hillcxest Country Estates
<br />8e. CITY OR TOWN OF DEATH (Include Zip Cods)
<br />Papillion 68133
<br />Id. COUNTY OF DEATH
<br />Sarpy
<br />se. RESIDENCE-STATE
<br />Nebraska
<br />tor. COUNTY
<br />Sarpy
<br />Se. CITY OR TOWN
<br />Papillion
<br />Id. STREET AND NUMBER
<br />6072 Grand Lodge Drivel
<br />ie. APT. NO.
<br />Ilf. ZIP CODE
<br />68133
<br />9 g. INSIDE CITY LIMITS
<br />® V " [ N.
<br />11
<br />105 MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Mernsal
<br />❑ Marled, but separated ® Widowed ❑ DWataed' QUnimown
<br />1 Ob. NAME OF SPOUSE (FIR, Middle, Last, el N wife, give maiden name.
<br />Lewis James
<br />11. FATHER'S -NAME (First, Middle, Last. Sum.)
<br />Anthony Braun
<br />12. MOTHER'S -NAME (First, Middle. Maiden Surname)
<br />Frances Bafweg
<br />12. EVER IN U.S. ARMED FORCES? Give dabs of service 11 Ves.
<br />(Yes, No, or Link.) No
<br />14a. INFORMANT -NAME
<br />( Shirley Hawk
<br />?4b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />18. METHOD OF DISPOSmON
<br />®°u"" ❑°onN1on
<br />❑cean don ❑F.rdeaM•a
<br />❑neaevdi ❑ah.N4P••sr)
<br />061 fat. EMBAt.MER -81ONA ''
<br />71dliM C .4QO�t
<br />lib. LICENSE 1 0.
<br />)77
<br />180. GATE (Mo., Day, Yr.)
<br />December 13, 2014
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />Westlawn Cemetery Grand Island Nebraska
<br />170. FUNERAL. HOME NAME AND MAILING ADDRESS (Street, City or Town, SINS)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. 21p Cods
<br />68801
<br />` CAUSE OF DEATH (See instructions and examples)
<br />1e. PMT L e.t.de t4455.00 ltlBle• dieeww litionsb or sompikationo DM410060 abreact the d0 8. DO NOT odertlwImI .seas such as cardiac ama, i APPROXIMATE INTERVAL
<br />'aspiratory snot, or nonsked& Swamies without Magid' te.aee4y DD NOT MBIEVIATI. Einar only en• ewea en • lino. Add additional Mod rn.aanery. II
<br />IMMEDIATE CAUSE: 6 E onset to dsatl1
<br />IMMEDIATE or CAUSE (Final 4 Jla 4 i i
<br />disease O<condlden resulting a) W , ` 4 �/ __ 2
<br />� rH
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />�,f
<br />SquentIa Iy list conditions, I b) 2.),,,,,....44.,-
<br />any, Wading to ds case listed , ...6Nr�, o5U" }ZD;
<br />i onset to death
<br />}
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter die UNDERLYING CAUSE c)
<br />own to death
<br />(dictate or Injury that Initiated } O nset 1p death swots „ in death) DUE TO, OR AS A CONSEQUENCE OF: !}
<br />LAST n
<br />d) } 1
<br />18. PART IL OTHER SKIN TD � contrIbufIng to IM dell butt not restating In She u / ndedying case given In PART 1. /
<br />A EnjG'GS hca..eJ Qp Cgbb+a. Veto 04..._ was er Aviv. ,44.40wP4.4, .HarLcprr �o. ea
<br />1& WAS MEDICAL EXAMINER
<br />OR CORONER ACTED?
<br />20. IF FEMALE:
<br />Not. pregnant within past year
<br />j - ❑Pregnant at dm* of death
<br />❑Not pregnant but pregnant within 42 days of death
<br />i ❑Not pregnant, but pennant 43 days to 1 year before death
<br />t [(Unknown I pregnant within the past year
<br />21a. MANNER OF DEATH
<br />Homicide
<br />®TNadral ❑ H
<br />❑ Aacidat ❑ Pending Inwstigadon
<br />❑ Suicld* ❑ Could not be debrndnsd
<br />21b. IF TRANSPORTATION INJURY
<br />olow
<br />❑ DoOpwtor
<br />❑ Passenger
<br />❑ Psdse4fan
<br />❑Odlsr (SPII IY)
<br />AUTOPSY PERFORMED?
<br />21c. WAS AN AUTO, ,,
<br />❑ YES ,
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />I.
<br />22a. DATE OF INJURY (Mo., Ow, Yr.)
<br />i t
<br />22b. TIME OF INJURY
<br />m
<br />22e. PLACE OF INJURY-At home, Yam, street, fectonb ernes WWII% eorsDfstlan sib, etc. (SpacNy)
<br />22d. INJURY AT WORK?
<br />DYES C]no
<br />22e. DESCRSIE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY • STREET A NUMBER, APT. 140. CITY/TOWN STATE MP CODE
<br />$
<br />it 236.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />/t/
<br />.$
<br />y k
<br />€ T��4
<br />a nd
<br />$
<br />O
<br />Og
<br />TISSUE DONATION
<br />(SI-NO
<br />244. DATE SIGNED (Mo., ay. Yr.)
<br />g
<br />2411. TIME OF DEATH
<br />.Are/1/40,-
<br />DATE SIGNED (MO., aY. Yr. N ) //
<br />I2,? 6/4
<br />230. TIME OF DEATH \
<br />227:24) > m
<br />a
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />23d. To Ms best of my knowledge, Math occurred
<br />O
<br />tw�o 1M _ t
<br />�t>/l! AAP "r
<br />28. • ilerr USE 0. UTE TO THE DEATH?
<br />❑ YES 21140 ❑PROBABLY ❑ UNKNOWN
<br />a
<br />and Title)
<br />lime, ms, date and place
<br />260. HAS ORGAN OR
<br />❑ YES
<br />24e. On the basis N rn
<br />a the time, dab and iliac*
<br />SEEN CONSIDERED?
<br />and/or d/or Investigation, In my opinion death occurred
<br />d to the (Signature stated. and Tide)
<br />lib. WAS CONSENT GRANTED?
<br />Not Applicable 1280 M NO DYES [❑ NO
<br />1 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />s'-l l...e .� c D fZ/ 50 AhAtskN if4vi ;./ 614,4r dAt4 .. #' .. F"
<br />28a. R SIGNATURE
<br />2
<br />.
<br />X41• '' - "`
<br />280. DATE FILED BY REGISTRAR (Mo., Dry, Yr.) I
<br />ni:'r 1 7 9f114
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT-OF W1c
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH ME NE ;r
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY HA,
<br />DATE OF ISSUANCE
<br />12/19/2014
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />STANLEY S
<br />ASSISTANT;
<br />DEPARTME
<br />HUMANS
<br />AN SERVICES, IT CERTIFIES
<br />NT OF HEALTH AND
<br />GISTRAR
<br />ALTHA
<br />
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