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HOSPITAL
<br />0 ERIOutpaIienl ❑ DOA
<br />OTHER
<br />,. Q Residence ❑ Other (e01)
<br />ag Inpatient
<br />Nursing Home
<br />WAS DECEDENT OF HISPANIC ORIGIN?
<br />(Specify yes or no below)
<br />If yes, specify Cuban. Mexican, Puerto Rican, etc.
<br />?. 01 NO O YES Specify
<br />RACE • White. Stack,
<br />American Indian, etc. (SPe0fy)
<br />a White
<br />DECEDENTS EDUCATION (Specify only hightest grade competed)
<br />EMmentary)Secondary (0.12)
<br />0. .. 12 "
<br />College (1-4 or 5 +)
<br />BIRTHRLACE
<br />(City 8 State or Foreign Country)
<br />10- .711nJ ato NE
<br />CITIZEN OF WHAT COUNTRY
<br />11. USA
<br />MARRIED. NEVER MARRIED,
<br />WIDOWED, DIVORCED (Spectbg
<br />123 - •.. a
<br />SURVIVING SPOUSE
<br />125.
<br />((fwlfe, give maiden name)
<br />SOCIAL SECURITY NU
<br />11. 505- 48.9931
<br />USUAL OCCUPATION (Give kind of work d ared 1ng most
<br />of workigg 3fe, Do not use retired.)
<br />a
<br />i . inspector
<br />KIND OP BUSINESS OR INDUS '
<br />1 4Manufacturing
<br />e a .7 T EVER IN U.S. ARMED
<br />SERVICES? (Specify yes or no)
<br />16 • Yes
<br />RESIDENCE • STATE
<br />1teTebraska
<br />COUNTY
<br />16 b. Hall
<br />CITY. TOWN, OR LOCATION
<br />IseGrand Island
<br />STREET NUMBER OR RESIDENCE
<br />1 *0•
<br />INSIDE CITY LIMITS
<br />(Specify yes DE NO
<br />1"
<br />0
<br />;71
<br />D
<br />tv.
<br />al
<br />BIRTH NUMBER
<br />DECEDENTS
<br />NAME
<br />1.
<br />SEX
<br />Male
<br />Final disease or condition
<br />resulting in death.
<br />Echart
<br />CERTIFICATE OF VITAL RECORD
<br />AGE - LAST BIRTHDAY
<br />(Years) 74
<br />FACILITY NAME 0(71 \ 1 Institution, give sheet and number
<br />65 . VA Medical Center
<br />NAME
<br />-INFORMANTS
<br />TAME JoAhn Frickey
<br />20a. METHOD OF DISPOSITION
<br />g Burial ❑ Cremation ❑ Removal from State
<br />•
<br />El Donation 0 other (Specify)
<br />FUNERAL DIRECTOR • SIG NfQyW z
<br />21a.
<br />23. MANNER O EATH •
<br />C Natural ❑ Investigation
<br />n
<br />o Accident
<br />❑ Suicide ❑ Could not be
<br />o Homicide determined
<br />To the best of my knowledge, death
<br />250. (Signature and Title)
<br />NAME AND TITLE OF ATTENDING PHYSICIAN IF
<br />26.
<br />Sequentially list conditions, if airy,
<br />leading to the immediate awe. Enter
<br />UNDERLYING CAUSE (Disease or
<br />injury that Initiated events resulting
<br />in death) LAST.
<br />31/11, 31/11,
<br />E T 1'
<br />NO
<br />OO
<br />ANY
<br />Herman
<br />UNDER 1 YEAR
<br />MUS.1 DAYS
<br />Ib.
<br />THER THAI CERTIFIER (TyperPrint)
<br />UNDER 1 DAY
<br />0117. I MIN.
<br />4c.
<br />IMMEDIATE CAUSE
<br />( ( a ) Pulmonar Kmbolisin.
<br />DUE TO (OR AS A CONSEQUENCE OF):
<br />PART Il.a. Other significant conditions conbibutIng 10 death but not resulting in the
<br />• underlying cause given in Part I.
<br />Cerebral Atrophy Secondary
<br />to Cerebral Vascular Disease
<br />STATEO•F IOWA
<br />IOWA DEPARTMET OF PUBLIC HEALTH 114-
<br />CERTIFICATE OF DEATI4
<br />FIRST MIDDLE LAST C A4 0
<br />VERN F FRICKEY
<br />DATE OF BIRTH (Mo. Day, Yr)
<br />s. January 31, 1928
<br />CITY, TOWN, OR LOCATION OF DEATH
<br />an. Knoxville
<br />be. PLACE OF UF_AI N ( wreck oni one
<br />NAME AND ADDRESS OF CERTIFIER (Physician or Medical Examiner) (Type/Print)
<br />• 27 Ghada Albeheary, MD, VACIHCS, 1515 W. Pleasant St., Knoxville, IA 50138
<br />26. PART I. Enter the diseases, injuries, or complications that caused the death. Do not enter the mode of dying, such as cardiac or respiratory artest,
<br />shock or heart failure. List only one cause on each line.
<br />yp a m ice St atus_Pns.t_Iiip._.Fz..(Lef.t..)
<br />00TO
<br />Ib) 0 (OR AS AC3NSEQUENC
<br />(c) .trim. Fibr-iil tion
<br />DUET (ORASR'CON1EOUENCE OF):
<br />(d)
<br />P.a tt a
<br />b. IF FEMALE, WAS THERE A
<br />• PREGNANCY IN THE PAST 12
<br />MONTHS?
<br />(Specify yes or no)
<br />CURRED
<br />29a.
<br />No
<br />hart N
<br />AUTOPSY
<br />• (Specify yes or no)
<br />2 Q t reOF TH (Mo. Day. Yr)
<br />1 2. October 14, 2002
<br />_COUNTY OF DEATH
<br />83 . Marion
<br />F.D. LICENSE a
<br />215. 2600`
<br />INSIDE CRY LIMITS
<br />e (SpeayLes es or no)
<br />d. Y
<br />MOTHE I M AA:O
<br />Frickey I1 Caroline Wilhemena Augustin
<br />MAILING ADDRESS (Street and Number or Rural Route Number, City or Town.: State, Zip Code)
<br />161,1304 W. Louise St. Grand Island,NR4NM
<br />PLACE OF DISPOSITION (Name of Cemetery, Crematory, LOCATION (City or Town, 31310)
<br />or other place)....
<br />_ 2 01Gedarview Cemeter 20 c• Doni
<br />- e
<br />FUNERAL HOME . NAME AND ADDRESS (Street Number or Run Route Number City or Town, State, 21p Code)
<br />21 c. 68801 Fai it1FnP)HnmP :2929 S Lon 1yt S Grad Ialsnd, � C E N E 0 1
<br />REGISTRAR • SIGNA ATE RECEIVE() BY REGISTRAR
<br />(Mo.,� v Yr.) 22a. � ... ' ' 22b. 2 4 m
<br />DATE INJURY
<br />(Mo.. Day, Yr.)
<br />24a.
<br />HOUR OF INJURY
<br />24b.
<br />INJURY AT WORK?
<br />(Spesily'Yea or no)
<br />24c.
<br />PLACE OF INJURY (Specify at home, farm. street, .
<br />factory, office building etc.) s ..
<br />24e.
<br />Route Number, City or town, State. Zip Code)
<br />HOUR OF DEATH
<br />25c. 12 :30 a M.
<br />Approximate
<br />Interval Between
<br />' Onset and Death
<br />WERE AUTOPSY FIND-
<br />INGS AVAILABLE PRIOR
<br />TO COMPLETION OF
<br />CAUSE OF DEATH?
<br />(Speofyyes o
<br />tab. No
<br />This is to certify that this is a .true and correct reproduction of the original record as recorded
<br />• in this office, issued under authority of Chapter 144, Code of Iowa.
<br />,JAN 0 2003 Thomas J. Vilsack
<br />•
<br />DATE ISSUED GOVERNOR, STATE OF IOWA STVE REGISTRAR OF VITAL RECO
<br />Sally J. Pederson, Lt. Governor
<br />FoRM #588- 0328s(2002) WARNING: IT IS ILLEGAL TO DUPLICATE THIS'COPY
<br />016 02018
<br />Immed_.
<br />2- Months
<br />$
<br />4617-'4* derfalMig
<br />ANY ALTERATION OH ERASURE VOIDS THIS CERTIFICATE
<br />� IT
<br />rla��lZ
<br />
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