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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND-HUMAALSERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINA Cf RD E ON Fk E WITH .
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT _ TIC S IO11F NIEH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />OCT 0 6 2006
<br />LINCOLN, NEBRASKA
<br />1. DECEDENT'S -NAME (First, Middle,
<br />Marvin James
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Buffalo County, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507 -48 -6802
<br />8b. FACILITY - NAME (If not institution, give street and number)
<br />Good Samaritan Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Ravenna 68869
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />49825 280th Road
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SCPPOF(T
<br />CERTIFICATE OF DEATH
<br />9b. COUNTY
<br />Buffalo
<br />10a. MARITAL STATUS AT TIME OF DEATH aMarried ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S•NAME (First, Middle, Last, Suffix)
<br />Otto Basnett
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes.
<br />(Yes, no or unk.) No
<br />15. METHOD OF DISPOSITION
<br />Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />Sequentially list conditions, If
<br />any, leading to the cause listed
<br />on line a.
<br />Enterthe UNDERLYING CAUSE
<br />(disease or Injury that Initiated
<br />the events resulting in death)
<br />LAST
<br />(d)
<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, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />22e DATF OF INJURY fUo., Day. Yr)
<br />22d. INJURY AT WORK?
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. N0.
<br />Z.
<br />Jo 5
<br />o.
<br />E 0
<br />E E O
<br />❑ YES ❑ NO
<br />23a. DATE OF DEATH (Mo , Day, Yr.)
<br />23b. DATE IGNED Mo., Day, Yr.)
<br />qt /OS Q6
<br />28a. REGISTRAR'S SIGNATURE
<br />16a.EMBA ATUR
<br />201601732
<br />Last,
<br />Basnett
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />86
<br />14a. INFORMANT -NAME
<br />Eileen Basnett
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(c) tr }t' C -�t�Q t9r`t.4 C iA,uJ'u 1
<br />220. TIME OF !Na! 1RV
<br />m
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />21a.M NNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ YES ❑ NO ❑ PROBABLY UNKNOWN ❑ YES
<br />❑ Accident0 Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />CITY/TOWN
<br />23c.TIME OF DEATH
<br />t2-: Foam
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title) y
<br />, I ��
<br />DEAT 7
<br />a$ ..c?.-1 EH z
<br />x u j
<br />S 33
<br />0 1 0
<br />U o
<br />44.o
<br />Suffix)
<br />5b. UNDER 1YEAR
<br />MOS.
<br />9c. CITY OR TOWN
<br />Ravenna
<br />DAYS
<br />9e. APT. NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Eileen Muhlbach
<br />12. MOTHER'S -NAME (First,
<br />Esther
<br />16b. LICENSE N0.
<br />910
<br />Sodtown Cemetery
<br />17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, State)
<br />Rasmussen Funeral Home - 311 Grand Avenue - Ravenna NE
<br />2. SEX
<br />Male
<br />HOURS
<br />8d. COUNTY OF DEATH
<br />Buffalo
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />TANEEY 5 IVR
<br />A$'SISTANT.STATE_RISTI R
<br />HEALTH AIWIti bVM N
<br />5c. UNDER 1 DAY
<br />91. ZIP CODE
<br />68869
<br />Buffa County
<br />(b) CG M-D - Wt ca b < -F'0, i 2 LU �- A g , 0.1 Li.c,LLu
<br />21b. IF TRANSPORTATION INJURY
<br />Li Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />25. DID TOBACCO US E CONTRIBUT TO 0 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Ishrat Saif, M.D. 104 West Seneca Street .. enna, NE 68869
<br />MINS.
<br />Middle,
<br />STATE
<br />24c. PRONOUNCED DEAD (Mo., Day,Yr.)
<br />30577
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />Sept. 24, 2006
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />January 30, 1920
<br />Be. PLACE OF DEATH
<br />HOSPITAL: ❑ Inpatient OTHER: Di Nursing Home /LTC ❑ Hospice Facility
<br />❑ ER /Outpatient ❑ Decedent's Home
<br />❑ DLV, ❑ Other (Specify)
<br />9g. INSIDE CITY LIMITS
<br />❑ YES , NO
<br />Malden Surname)
<br />Urwiller
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16c. DATE (Mo., Day, Yr. )
<br />September 28, 200•
<br />CITY /TOWN STATE
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />❑ YES XNO
<br />Nebraska
<br />17b. Zip Code
<br />68869
<br />APPROXIMATE INTERVAL
<br />18. PART I. Enter the chain of events -- diseases, Injuries, or complications - -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final (a) C 1, 1 4 iR41 PNUA G I j o b
<br />disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />In death)
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ❑ NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />?2c. P1 ACE OF1N.rltlV.At hnnta, farm_ straar factory, ...Moo Iwpding cnnF.tr,Mlon site, etn. (Bnonily)
<br />24b.TIME OF DEATH
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES
<br />ZIP CODE
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />m
<br />24e. On the basis of examination and /or Investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title) y
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />SEP 2 9 2006
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