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<br />DOUGLAS COUNTY HEALTH DEPARTMENT
<br />4738 VITAL STATISTIC$ SECTION - OMAHA, NEBRASKA
<br />CERTIFICATE OF DEATH o
<br />This eertiffes,thfs�j"ent'to be a true copy of an original record on file
<br />with the Vital 9ta.tisti"b'd'.ection of the Douglas County Health Department,
<br />Omaha, Nebraska. CeYt-ifl:; d copies must have a raised seal in the area to the
<br />left. Reproductions of this green certificate are not legal copies.
<br />Date issued:-.- I OCT 'r 1
<br />N.
<br />Registrar)
<br />200107383
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<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH (Monts, Day, Year)
<br />Henry Hicks Jennelle
<br />Male
<br />September 29, 1993
<br />a. CITY AND STATE OF BIRTH (d not in U.S.A., name country)
<br />5a. AGE - Lost Birthday I
<br />UtID
<br />8. DATE OF BIRTH (Mondr. Day. Year)
<br />SD. MOS. DAYS
<br />5c. HOURS MINS,
<br />(Yrs.)
<br />1
<br />Corrine, West Virginia
<br />48
<br />1
<br />June 17 1945
<br />7. SOCIAL SECURITY NUMBER
<br />Be. PLACE OF DEATH
<br />HOSPITAL: ]0 Inpatient ❑ ER /Outpatism ❑DOA
<br />232 -70 -_5951
<br />OTHER : ❑ Nursing Home ❑ Residence ❑ Other (Specify)
<br />8D. FACILITY - Name (H not ins trhrtron, gips sheet and number)
<br />8c. CITY, TOWN OR LOCATION OF DEATH
<br />0a. INSIDE CITY LIMITS
<br />h. COUNTY OF DEATH
<br />VA Medical Center
<br />Omaha
<br />(Specify Yea a NO)
<br />Yes
<br />Douglas
<br />Be. RESIDENCE -STATE
<br />9b. COUN
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including Zip Code)
<br />9e. INSIDE CITY LIMITS
<br />110.
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1116 East 5th St.
<br />(Specify Yes of No)
<br />Yes
<br />RACE - (eq.. While, Black, American Indian,
<br />etc.) (specify/
<br />11. ANCESTRY (e.g.,ltalian, Mexican, German, etc.)
<br />12. MARRIEDNEVER MARRIED.
<br />NAME OF SPOUSE (d ode. give maiden name)
<br />(Specify/
<br />WIDOWED, DIVORCED (Specify/
<br />White
<br />Married
<br />113.
<br />Sheryl Sexton
<br />file. USUAL OCCUPATION (Give kind d work done during most
<br />tsb. KIND OF BUSINESS INDUSTRY
<br />i I N i 1 hi h t r m t
<br />d waking /No, even it retired)
<br />Elementary or Secondary (0 -12) College (1 -a or 5 -1
<br />Salesman
<br />Home Improvement
<br />12
<br />18. FATHER -NAME FIRST MIDDLE UST
<br />17. MOTHER - MAIDEN NAME FIRST MIDDLE UST
<br />Thomas Jennelle
<br />Addie Johnson
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19. ANFORMANT - NAME - MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP)
<br />(Yes, no, a unk.) (11 yes, give war and dates of services)
<br />-._ - _ _ _. __ _
<br />Yes 8 -12- 65/10 -x-68 VA Medical Center, 4101 Woolworth Ave.,Omaha�NE
<br />20s. BURIAL, Cremabon,Removel,
<br />Donation
<br />20b. DATE
<br />20c. CEMETERY OR CREMATORY - NAME 20d.
<br />LOCATION CITY OR TOWN STATE
<br />Burial
<br />Oct. 4, 1993
<br />Harris Grove
<br />Logan, Iowa
<br />21. EMBALMER •SIGNATURE 8 LICENSE NO.
<br />22. FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP) _
<br />/s /W. Scott Schumacher #2053
<br />5A
<br />Schumacher Funeral Home, 215 N. 4th Ave., Logan jA6
<br />23. PART IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (q) 1 Interval between onset and death
<br />I
<br />' Cardiopulmonary Arrest Immediate
<br />DUE TO, OR AS A CONSEQUENCE OF: t Interval between onset and death
<br />Chronic Renal Failure
<br />IN I Months
<br />I
<br />DUE TO. OR AS A CONSEQUENCE OF: I Interval between onset and beath
<br />Icl I
<br />Non-Hodgkins Lymphoma Months
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to death but not related
<br />PART
<br />PART III IF FEMALE, WAS THERE A
<br />125.
<br />WAS CASE REFERRED TO MEDICAL
<br />g PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />(Specify Yes a No)
<br />EXAMINER OR CORONER?
<br />Yes ❑ No ❑
<br />Yes
<br />(Specify Yes or 481
<br />N
<br />28a. ACCIDENT, SUICIDE, HOMICIDE,
<br />26b. DATE OF INJURY (Mo.,Day, Yr.)
<br />26c. HOUR OF INJURY
<br />DESCRIBE HOW INJURY CURRED
<br />OR PENDING INVESTIGATION /Specify/
<br />Spft*l,
<br />1 1,01
<br />126d.
<br />260. INJURY AT WORK
<br />26f. PUCE OF INJURY - At home, farm, sheet, factory, 26q.
<br />LOCATION STREET OR R.F.D. N0, CITY OR TOWN STATE
<br />(Specify Yes or NO)
<br />office building, etc. /specm
<br />27s. DATE OF DEATH /Mo. Day, Yr.)
<br />28a. DATE SIGNED (Mo., Day, Yr.)
<br />28b. TIME OF DEATH
<br />September 29, 1993r
<br />s
<br />s uQs
<br />27b. DATE SIGNED (Mo., Day, Yr.)
<br />27a TIME OF DEATH
<br />28c. PRONOUNCED DEAD (MO.. Day. Yt)
<br />280. PRONOUNCED DEAD (Hour)
<br />�
<br />9 -30 -93
<br />9:05 P.M. M
<br />>s
<br />M
<br />To Me best of my knowledge, death Occurred at the time, date and place and due to the
<br />280. On me basis of examination and of investigation, in my opinion death occurred at
<br />s27d.
<br />a a
<br />ClU90) stated.
<br />the hme, date and place and due to the cause(s) staled.
<br />nanse and T ► s� no M . D .
<br />fsi nawre and-Ti - - - -- -
<br />29a. 010408A000 GS£
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30b.
<br />WAS CONSENT GRANTED?
<br />O YES p'NO -n�_`. 7 vyy UNKNOWN
<br />r.
<br />❑ YES �NO
<br />YES NO
<br />31. NAME AND ADDRESS OF CEFWrT4#PIE YSICAN, CO ' ..S ICAN OR COUNTY ATTORNEY( (Type or Print/
<br />.. t gyp• ..i.
<br />Jorge n�� M,D. VA MI& /cal Center 101 Woolworth Ave Omaha NE 68105
<br />.
<br />32s. REGISTRAR If
<br />�� ' . '
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr)
<br />9 1141
<br />OCT 7 1993
<br />This eertiffes,thfs�j"ent'to be a true copy of an original record on file
<br />with the Vital 9ta.tisti"b'd'.ection of the Douglas County Health Department,
<br />Omaha, Nebraska. CeYt-ifl:; d copies must have a raised seal in the area to the
<br />left. Reproductions of this green certificate are not legal copies.
<br />Date issued:-.- I OCT 'r 1
<br />N.
<br />Registrar)
<br />200107383
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