1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Ronald Eugene Matheson
<br />4. CITYAN
<br />D STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Laramie, Wyoming
<br />7. SOCIAL SECURITY NUMBER
<br />520 -48 -7531
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />518 Cottonwood Street
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />73
<br />9b. COUNTY
<br />Howard
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />❑ DOA ❑ Other (S
<br />9c. CITY OR TOWN
<br />St. Libory
<br />8d. COUNTY OF DEATH
<br />Howard
<br />IX
<br />b
<br />w
<br />DC 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />St. Libory 68872
<br />cc 9a. RESIDENCE -STATE
<br />z Nebraska
<br />7. 9d. STREET AND NUMBER
<br />j, ' 515 Cvtt.Or.�rc3id J....c t
<br />a
<br />N
<br />=
<br />Si
<br />IL)
<br />4
<br />0.
<br />10a. MARITAL STATUS AT TIME OF DEATH El Married ❑ Never Married
<br />❑ Married, but separated; ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Roy Matheson
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 01/24/1968-01/12/1970
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation
<br />® Cremation ❑ Entombment
<br />❑ Removal © Othec:(Specify)
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Peters Funeral Home. 302 Second Street. PO Box 181. St. Paul. Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of eJei is -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />re$ piratory 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:
<br />IMMEDIATE CAUSE (Final a) Sudden Cardiac Death
<br />disease or condition resulting
<br />in death)
<br />Sequentially list conditions, if
<br />any, leading to the Cause listed
<br />on lines.
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury that initiated
<br />the events resullmgan death)
<br />LAST
<br />LL 20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />UJ ❑ Pregnant at time of death
<br />rt
<br />16a. EMBALMER - SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Coronary Artery Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Hypertension
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden n
<br />Sharon L Kleinschmidt
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Evelyn Wilkins
<br />14a. INFORMANT- NAME
<br />Sharon L Matheson
<br />Gibbon
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />16b. LICENSE NO.
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />21b, IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />onse
<br />Min
<br />1
<br />WHEN ! THIS !''COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />1/4/2017
<br />LINCOLN, NEBRASKA
<br />❑ Nat pregnant, but pregnant within 42 days of death
<br />T Not nregnattt, NA pregnant. 43 days to 1 year before death
<br />❑ Unknown if pregnant Within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22d. INJURY AT WORK7
<br />YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />S ATE SIGNED (Mo., Day, Yr.)
<br />•
<br />23c. TIME OF DEATH
<br />3d. 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)
<br />28a REGISTRAR'S SIGNATURE
<br />201702625
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />❑ Suicide ❑ Could not be determined
<br />CITY/TOWN
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC
<br />0 ER/Qutpatient ® Decedent's Home
<br />fl*
<br />*
<br />. APT. NO.
<br />❑ Pedestrian
<br />0 Other )Specify)
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />9f. ZIP CODE
<br />6 5872
<br />STATE
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 28, 2016
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />October 11 1!'
<br />pecify)
<br />onset
<br />ame
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />December 29, 2016
<br />2 4c. PRUNUUivf,ED GEMO (Mo., Day, Yr.). Z4d. TfME PRONOLi . .
<br />December 28, 2016 05:46 PM
<br />u C
<br />8 z 'o
<br />12 2
<br />o David T. Schroeder, Howard County Attorney
<br />❑ Hospice Facility
<br />28b. DATE FILED BY REGISTRAR (MO.
<br />December 29, 2016
<br />9g. INSIDE CITY LIMITS
<br />I w VES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo, Day, Yr.)
<br />December 29, 2016
<br />STATE
<br />Nebraska
<br />17b. Zip code
<br />68873
<br />APPROXIMATE:INTERVAL.
<br />to death
<br />utes
<br />onset to death
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />El YES 0 NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABL
<br />TO COMPLETE CAUSE OF DEATH ? :,
<br />LJ ONr
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />24b. TIME OF DEATH
<br />Approx. O5:25 PM
<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)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN €OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />El YES ❑ NO ❑ PROBABLY ® UNKNOWN ❑ YES 1E NO Not Applicable if 26a is NO ❑ YES
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />David T. Schroeder, Howard County Attorney, 612 Indian St., Ste 3, St. Paul, Nebraska, 68873
<br />"ZIP; CODE
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