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To Be CompletedlVerified by: FUNERAL DIRECTOR <br />1 <br />--------- - - - - -- - - - - -- <br />1. DECEDENTS -NAME (First, Middle, lest Suffix) <br />Shirley Ann Johnson <br />2. SEX <br />Female <br />3. DATE OF DEATH (Mo.,Day,Yr.) <br />September 8, 2015 <br />4 CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH <br />Jasper, Alabama <br />6e. AGE -Lot Birthday <br />(Yrs.) <br />68 <br />6b. UNDER 1 YEAR <br />6e. UNDER 1 DAY <br />6. DATE OF BIRTH (Mo., Day, Yr.) <br />December 20, 1946 <br />MOS. <br />DAYS <br />HOURS <br />MINS. <br />7. SOCIAL SECURITY NUMBER <br />507 -56 -2490 <br />6a. PLACE OF DEATH <br />tss2 9L: ❑ mpetl.nt Q11(& ® Nursing NomM.TC ❑ Hospice Facility <br />❑ ER/Outpatient ❑ Decedent's Horns . . <br />❑DOA ❑otnar(SpeeHy) <br />6b. FACILITY-NAME (I not institution, ghat street and number) <br />CHI Health St. Francis <br />Se. CRY OR TOWN OF DEATH (Include 2Ip Code) 1 <br />Grand Island 68803 <br />bd. COUNTY OF DEATH <br />Hall <br />Oh RESIDENCE -STATE <br />Nebraska <br />96. COUNTY <br />( Hall <br />9e. CITY OR TOWN <br />Cairo <br />Id. STREET AND NUMBER <br />204 Suez Street <br />9.. APT. NO. <br />9f. ZIP CODE <br />68824 <br />9g. INSIDE CITY LIMITS <br />® Yet ❑ No <br />10a. MARITAL STATUS AT TIME OF DEATH ®Married y] New M <br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown <br />16b. NAME OF SPOUSE (Fs% Middle, Last, Suffix) B wife, give maiden name. <br />Francis Johnson <br />11. FATHER'S -NAME (First Middle, Last, SriIx) <br />LeRoy F Brown <br />12. MOTHER'S -NAME (First, Middle, Maiden Surname) <br />Elsie Stutzman <br />13, EVER IN U.S. ARMED FORCES? GM data of service N Yes. <br />(Yes, No, aunll-) N <br />14a. INFORMANT -NAME <br />Francis Johnson <br />14b. RELATIONSHIP TO DECEDENT <br />Spouse <br />16. METHOD OF DISPOSITION <br />®'°"" 0 °onto'°" <br />Dammam ❑eMwnemmt <br />❑ReaeW ❑Galto(apeeify) <br />164 ENO ER -SIONATUR <br />P <br />� ETERY, <br />16b. MIENS! NO. <br />/2 y o <br />16c. DATE (Mo., Day, Yr.) <br />September 12, 2015 <br />1St TORY OR OTHER LOCATION CITY/TOWN STATE <br />Mt. Pleasant Cemetery Cairo Nebraska <br />174 FUNERAL HOME NAME AND MAIJNG ADDRESS (Street. City or Town. Sage) <br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska <br />I 17b. Zp Code <br />68801 <br />To Be Completed by: CERTIFIER <br />CAUSE OF DEATH (See instructions and examples) <br />18. PART I. OW MO 80101.0(.0.11181- dirooroo, 114mw, or wmpae.aam -mm erectly mood the dwlh. 00 NOT onto, Moir' mole each or maw ornwt. APPROXIMATE INTERVAL <br />m.pbetory moot. orwmmerer nbmlrbn without domino e. rtolopy.00 NOT AMIMVIATa into, only one Beeo on • eat. Add additional lbw I n.w.1toy. <br />IMMEDIATE CAUSE: *nod to death <br />IMMEDIATE CAUSE (Fbtat /' �u /1 .2° Woe <br />d or .t �j re 6aacPr(A / �t Are1F/44 M ,o- Xreast 1440AA9 <br />in death) <br />DUE TO, OR AS A CONSEQUENCE OF: / onset to death <br />SsquentlaNy Iles conditions, N b) <br />arty, leading to Uta eau* listed <br />on Ire a. DUE T0, OR AS A CONSEQUENCE OF: onset to (Math <br />Enter the UNDERLYING CAUSE a) <br />(rile.... or InJury that kthtlated <br />the 9ya resu in death) DUE 70, OR AS A CONSEQUENCE OF onset to death <br />LAST <br />4) <br />t <br />19. PART E OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the dead) but not resulting in the underlying Douse given M PART I. <br />19. WAS MEDICAL EXAMINER <br />OR CORONER CONTACTED? <br />❑ YES to NO <br />20. 11 FEMALE: <br />lot pregnant within pat year <br />❑Pregnant at time M death <br />❑Net prsptalt but Prsgrtant within 42 days of death <br />❑Net ptegrl•nt but poignant 43 days to 1 yaw before death <br />❑Unknown N prs0lant within 1M past year <br />214 MANNER OF DEATH <br />AN.... ❑ Homtclde <br />❑ Accident ❑ Pending investigation <br />❑ stickle ❑ Could net a dsemdnsd <br />21b. IF TRANSPORTATION INJURY <br />❑ Driver/Operator <br />❑ Passenger <br />❑ Pedestrian <br />❑ Other ISp•wyl <br />210. WAS AN AUTOPSY PERFORMED? <br />❑ YES a NO <br />2141. WERE AUTOPSY FINDINGS AVAILABLE <br />TO COMPLETE CAUSE OF DEATH? <br />❑ Yes ❑ No <br />22a. DATE OF INJURY (Mo., Day, Yr.) 1 <br />22b. TIME OF INJURY <br />m <br />22c. PLACE OF INJURY -At hems, burs, 80.91, factory, office building, cohabitation , ate. (SPedfy) <br />224. INJURY AT WORK? <br />❑ YES ❑ NO <br />22e. DESCRIBE NOW INJURY OCCURRED <br />2Z LOCATION OF INJURY - STREET & NUMBER, APT. N0. CITY/TOWN STATE ZIP CODE <br />ii <br />Z. j <br />2 g <br />o yI <br />1- a <br />234 DATE OF DEATH (Mo., Day , Yr.) /� I <br />/ <br />1 } C r <br />a. >- <br />8 <br />O § <br />24a. DATE SIGNED (Mo., Day, Yr.) <br />24b. TIME OF DEATH <br />Day, Yr.) <br />23b. DATE SIGNED (Mo., D <br />oq// /�.e/5 <br />23c. TIME OF DEATH <br />IM <br />/a *.2d� • Pm <br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) <br />24d. TIME PRONOUNCED DEAD <br />m <br />23d. To the best of my knowledoe. death occu sd re the dine, date end piece <br />and due a the cause(*) sated. (Signature end Tate) <br />21st. On the desk a examination and/or irnatlgetlon, M ny eplMen WWII ooaumd <br />at the tics, date and piece and ,Are to the eawe(e) stated. (Signature and TNN) <br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />❑ YES a,N0 ❑ PROBABLY ❑ UNKNOWN <br />269. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />RI'!S ❑ NO <br />26b. WAS CONSENT GRANTED? <br />Not Applicable a 26a Is NO ❑ YES Am NO <br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Typs or Phnt) <br />Thomas Werner M.D. 810 N. Dier - Avenu , Grand Island, NE 68803 <br />P <br />269. REGISTRAR'S SIGNATURE ����,,,,����,, <br />i nCift"" T i <br />29b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) <br />SEP 21 2015 <br />STATE OF NEBRASKA <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMANSERVICES, IT CERTIFIES <br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA OF HEALTH AND <br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL. PECORDS <br />DATE OF ISSUANCE <br />09/23/2015 <br />LINCOLN, NEBRASKA <br />201707713 <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE'S <br />v <br />STANLEY S. COOPER <br />ASSISTANT STATE REGISTRAR, <br />DEPARTMENT :Of HEALTH J4ND <br />HUMAN SERVICES <br />15 <br />26375 <br />