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J To Be CompletedNerified by: FUNERAL DIRECTOR
<br />1
<br />1. DECEDENTS-NAME (First, Middle. Last, Suffix) - _ 2.
<br />Floretta Margaret Ward
<br />SEX t
<br />Female
<br />5c. UNDER 1 DAY
<br />m vasvv •
<br />3. DATE OF DEATH (Mo..DayYr.)
<br />January 5, 2016
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Sturgis, Kentucky
<br />5a. AGE-Last Birthday
<br />(Yrs.)
<br />88
<br />5b. UNDER 1 YEAR
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />April 9, 1927
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />361 -16 -5019
<br />8a. PLACE OF DEATH
<br />HOSPITAL: ❑ Inpatient OTHER; ❑ Nursing Home/LTC ❑ Hospice Facility
<br />86. FACILITY -NAME (If not Institution, give street and number)
<br />Elk Ridge village
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68022
<br />❑ ERiOutpetient ❑ Decedent's Home
<br />❑ DOA RI OlherSpaclylASSISTED LIVING
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Douglas
<br />8c. CITY OR TOWN
<br />Omaha
<br />9d. STREET AND NUMBER
<br />19400 Elk Ridge Drive
<br />ga. APT. N0.
<br />138
<br />9f. ZIP CODE
<br />68022
<br />9g. INSIDE CITY LIMITS
<br />® Yes ❑ No
<br />_
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑Married ❑ Never Married
<br />❑ Married, but separated ® Widowed 0 Divorced ❑ Unknown
<br />106. NAME OF SPOUSE (Fiat, Middle, Last, SWIM) I wife, give maiden name.
<br />11. FATHER'S-NAME (First, Middle, Last, Suffix)
<br />Geor.e Marshall Sullivent
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Anna Judell Holt
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service I Yes.
<br />(res, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Michael L Smith
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />15. METHOD OF DISPOSITION
<br />I Bnriw ❑Donlon
<br />❑Cremation ❑Etombmam
<br />❑Ramovd OothadBpaeNy)
<br />15a. j ALME2- SIGNATURE
<br />(X/t...
<br />160. UG'ENSE NO.
<br />1 c.z l.L
<br />16e. DATE (Mo., Day, Yr.)
<br />Janu 9, 2016
<br />164. CEMETERY, MATORY CR OTHER LOCATION CITY/TOWN STATE
<br />Forest Lawn Memorial Park Cemetery Omaha Nebraska
<br />(7a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Crosby- Burket- Swanson - Golden Colonial Chapel, 11902 W. Center Road, Omaha, Nebraska
<br />176. Zip Code
<br />68144
<br />13 To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />it. PART I. Enter the sawn Mwmda. dimesea, Injuries, a complication. that directly weave the death. DO NOT enter nominal events such tie cardiac aunt, APPROXIMATE INTERVAL
<br />otsplotiry motet. or ventricular ebritiaaon without showing the etiology. DO NOT ABBREVIATE. Ems, only one Cauca on a line. Add additional /Inca it neesee•y.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final �t'a J ) r
<br />disease or condition resulting at n ' t L
<br />In death) may' ✓7�v ( �LQ_ tern 5 �5 ‘
<br />/q
<br />DUE TO, OR AS A CONSEQUENCE OF: L onset W death
<br />Sequentially list conditions, S
<br />any, leading to the cause listed 11)
<br />en dna a. DUE 70, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE 01
<br />(disease or Injury that initiated
<br />the events resulting in dtrath) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST
<br />d)
<br />10. PART D. OTHER SIGNIFICANT CONDmONS•Condrnonns contributing to the death but not reuniting In the underlying cause given in PART 1
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />El YES ❑ NO
<br />20. IF FEMALE:
<br />J t pregnant within past year
<br />[] Pregnant at time of death
<br />0Not 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. NER OF DEATH
<br />Natural D Homicide
<br />❑ Accident ❑ PetM{ng hnesOgagon
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION ( NJURY
<br />❑ Driver/Operator
<br />Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ®NO
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. ME OF INJURY
<br />m
<br />224. PLACE OF INJURY -At home, fans, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />2 W
<br />Januar
<br />17 IA
<br />r
<br />n w r
<br />o no
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 5 2016
<br />r
<br />2
<br />W
<br />.0 222
<br />24a. DATE SIGNED (Mb., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />23b. DATE SIGHED (Mo., Day, Yr.)
<br />/' ZdT f
<br />23c. TIME OF DEATH
<br />7:10 A. m
<br />_`
<br />a g re
<br />m = O r
<br />Sufi z
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />_
<br />m V 23d. To the best of wledge, death occu a t the time, date and place
<br />o W and due t causes) state 1 and Title)
<br />�
<br />gi,
<br />u w 2 O
<br />Z O C
<br />I- o v
<br />o
<br />24e. On the basis of examination andlor Inveat(gation, In my opinion death occurred
<br />at tie time, dat and place and due to the cause(s) stated. (Signature and Title)
<br />25. USE CONTRIBUTE TO THE O TH? 0,......,_
<br />YES 0 NO - - 0 rROaaeLY- -� LAIKtgeWr4
<br />26a. HAS ORGAN CR TISSUE DONA� N BEEN CONSIDERED?
<br />❑ yes .� " 0 0
<br />266. WAS CONSENT GRANTED?
<br />Not Applicable ti 26a is NO ❑ YES ❑ NO
<br />27. NAME. TITLE AND A DRESS CERTIFIER (Type cc Print)
<br />4 ,4 7 s e� ° tr+£r,s ... s iS 3..r,/ .C9 ! u q 4 .mil/ '/
<br />26a. REGIS - _ q f . -
<br />.... �a �a4 laa w , a �w � i awi * ars
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JAN142.016
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />This certifiaithisdocument to be a Prue copy of an original record on file with Vital Statistics, Douglas
<br />County Heald'- Dept:, Omaha, Nebraska. Certified copies must have a raised seal in the area to the left.
<br />Reproduction of this `gieen.certificate;are not legal copies.
<br />Date Issued: J.ANt 14 2016 Registrar:
<br />20 1600504
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