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
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