|
1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Howard Warren Bacon Jr.
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 18, 2007
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE -Last Birthday
<br />(Yrs.) 80
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />February 8, 1926
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />508-18-9077
<br />8a. PLACE OF DEATH
<br />HOSPITAL• ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br />" -
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />512 E. Koenig St.
<br />❑ ER /Outpatient a Decedent's Home
<br />❑ IXt4 ❑ Other(Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />512 E. Koenig
<br />9e. APT. NO
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />131 YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH I Married ❑ Never Married
<br />❑ Married, but separated CI Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Lest, Suffix) If wife give maiden name.
<br />Lorraine Stroh
<br />11. FATHER'S -NAME (First, Middle, Last, Suiflx)
<br />Howard Warren Bacon Sr.
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Kathryn Noaecker
<br />MEYER e S IN U.S. ARMED FORCES? Give dates of service If yes.
<br />(Yes, no, or unk.)1 2/31 /43,- 5/1
<br />14a.INFORMANT -NAME
<br />Lorraine Bacon
<br />14b. RELATIONSHIP TO DECEDENT
<br />wife
<br />16c. DATE (Mo., Day, Yr. )
<br />January 22, 2007
<br />15. METHOD OF DISPOSITION
<br />ii Burial ❑Donation
<br />O Cremation ❑ Entombment
<br />❑Removal ❑ Other (Specify)
<br />16f.EMBALMER -SIGN /
<br />d /)f7de„r
<br />16b. LICENSE NO.
<br />1 071
<br />16d. CEMETERY, CREMATORY OR OTHER LO ION CITY /TOWN STATE
<br />Westlawn Memorial Park Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust St. Grand Island,NE
<br />�T
<br />.2r.A
<br />18. PART I. Enter the chain of events -- diseases, injuries, or complications- -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Ilnes If necessary.
<br />IMMEDIATE CAUSE: 1 onset
<br />IMMEDIATE CAUSE (Final (a) N G s V \Q i 1C.. •F-A.4-7 C( .-Q . -
<br />17b. Zip Code
<br />68801
<br />INTERVAL
<br />to death
<br />0 S
<br />disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />in death)
<br />Sequentially list conditions, it (b) t.,S7 PN q y L W C e,:\ L S " e S `S I 0 Pt-y
<br />any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />.,,.c on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that initiated (c)
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />LAST
<br />•
<br />(d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />a
<br />a ¢
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES X NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />t r SC ', ❑ Unknown If pregnant within the past year
<br />21a. MANNER OF DEATH
<br />tDriver/Operator
<br />ural ❑ Homicide
<br />CI Accident❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /0 P
<br />❑Passenger
<br />9
<br />❑Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES l0
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />❑ YES
<br />site, etc. (Specify)
<br />22a. DATE OF INJURY (540., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At home, farm,
<br />street, factory, office building, construction
<br />off 22d. INJURY AT WORK?
<br />DYES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />y 'r! 221. LOCATION OF INJURY - STREET 8 NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />a s
<br />• t s }
<br />Eaz
<br />m 0) p
<br />v
<br />1
<br />a
<br />23a. DATE OF DEATH (Mo., Day, Yr.) Z y 24a. DATE SIGNED (Mo., Day,
<br />January 18, 2007 as=
<br />m
<br />24b. TIME OF DEATH
<br />m
<br />23b. DATE SIGNED (Mo., Day, Yr.) -
<br />OA- Y cool_
<br />23c. TIME OF DEATH .1 s C' 24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />02: 35 a .m EE
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />23d. To the best of my knowledge, death occurred at the time, date and place 8 ill Z O 24e. On the basis of examination and /or investigation,
<br />u the cause stated. (Signet e and Title ) • 2 ¢ u the time, date and place and due to the
<br />2 rdc.\t- M 0 0 °
<br />In my opinion death occurred at
<br />cause(s) stated. (Signature and Title ) •
<br />25. DID TOBACCO USE CONTRIBUTE TOTHE DEATH?
<br />❑ YES O ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES • (Lt`�0.
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />John Cannella,M.D., 729 N. Custer Ave.,Grand Island, Nebraska 68803
<br />1 284: REGISTRAR'S SIGNATURE
<br />1 , i
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JAN 21 2007
<br />STATE OF NEBRASKA 201805072
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORRD ON FILE, WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL SJ4TiS - TICS SLCTIZff _WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. = �_
<br />DATE OF ISSUANCE
<br />JAN 3 1 2007
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPOFij 7 2 O 695
<br />CERTIFICATE OF DEATH f
<br />d TA NLEY S. COOPER
<br />ASSISTANT STATE RE GISTRAR
<br />- HEALTH AND HUMAV SERVICES
<br />
|