|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTk{-AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRACC4 PEP. RTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FORV1,$L RECORDS.
<br />DATE OF ISSUANCE
<br />APR 01 2009
<br />LINCOLN, NEBRASKA
<br />20180673.1
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH. AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPOr 9 22731
<br />CERTIFICATE flF P)FATH
<br />s -•
<br />§.t.`-. 1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Maxine Lucille O'Hern
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Vr.)
<br />March 17,2009
<br />Mj r 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE -Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />xT. Merrick County, Nebraska
<br />Y
<br />(rs.)
<br />78
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />June 26, 1930
<br />7. SOU AL SECURITY NUMBER
<br />5(08-68-1627
<br />8a. 'LACE Of DEATH
<br />.iQ•"> ITA V Inp:dient OTHO: I...) Nursing Home/LTC Li Hospice Facility
<br />''
<br />85. FACILITY -NAME (If not institution, give street and number)
<br />Bryan LGH East Medical Center
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />❑ ooa ❑ Other (Specify)
<br />;'A
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Lincoln 68506
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Merrick
<br />9c. CITY OR TOWN
<br />Palmer
<br />9d. STREET AND NUMBER
<br />809 Omega St.
<br />9e. APT. NO
<br />91. ZIP CODE 9g. INSIDE CITY LIMITS
<br />68864 I 23 YES 0 NO
<br />kn
<br />'car
<br />10a. MARITAL STATUS AT TIME OF DEATH 2 Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife give maiden name.
<br />Barney 0' Hern
<br />rd
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Max rauen
<br />112. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />I Elsie Ostermeier
<br />13 EVER IN U.S. ARMED FORCES? Give d service f yes.
<br />no, or U.S No
<br />(Yes,arney:
<br />.. INFORMANT -NAME
<br />O'Hern
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />C
<br />15. METHOD OF DISPOSITION
<br />2Burial ❑Donation
<br />16a r :ALM '-' IGNAT RE
<br />41/, i itti .0;Ali A
<br />16b. LICENSE NO.
<br />892
<br />16c. DATE (Mo.. Day, Yr. )
<br />March 20, 2009
<br />❑ Cremation ❑ Entombm.
<br />0 Removal 0 Other (•. ecify)
<br />16d. s METERY, CREMATORY 0- :THER LOCATION CITY / TOWN STATE
<br />Ros- Hill Cemetery Palmer NE
<br />hth'
<br />17a. FUNERAL HOME NAME AND MAIL • : ' ESS (Street, City or Town, Slate)
<br />Palmer Funeral Home, 210 Irving, P.O. Box 332, Fullerton, NE
<br />17b. Zip Code
<br />68638
<br />..:
<br />t
<br />,1 1.,5. B'w"' ;' ornwn-a �` .$%'�Y", i1 YQF 'iF•K9>Z<a 'ar ::yt' a. _.: jyX,+ `w"'
<br />n.F..v
<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 INTERVAL
<br />41x.
<br />{
<br />respiratory 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: onset to death
<br />_ G/'
<br />IMMEDIATE CAUSE (Final (a) (sk,I.'
<br />'�-
<br />disease or condition resulting DUE TO, OR AS A CONSEOUEN OF: l onset to death
<br />In death) i Ar ,/�/J�
<br />Sequentially list conditions, 11 Al 2/ •` k �!^��{r'r i v{,/ VaChri`rt
<br />any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />on linea. �`J',//1 /`�/,f/A{ /�/7
<br />Enterthe UNDERLYING
<br />thatCAUSE
<br />(disease or injury that initiated lbl
<br />ted (c) ►-N / •• Y
<br />the events resulting in death) DUE TO. OR ASACONSEQUENCE OF: onset to death
<br />lA4f
<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 />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ❑ NO
<br />W`
<br />•; tS ,
<br />20.IF FEMALE:
<br />0 Not pregnant within past year
<br />❑Pre Pregnant at time of death
<br />9
<br />21a. MANNER OF DEATH
<br />0 Natural 0 Homicide
<br />0 Accident Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />M�/
<br />X YES 0 NO
<br />',pg$
<br />0 Not pregnant, but pregnant Y
<br />within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />❑ Suicide 0 Could not be determined
<br />❑Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE 06 DEATH?
<br />0 YES .ex N0
<br />r 4;:
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b, TIME OF INJURY
<br />m
<br />1 22c. PLACE OF INJURY -At home, farm,
<br />street, factory, office bui;:ling, construction
<br />site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES 0 NO
<br />-1'
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22t. LOCATION OF INJURY -STREET 8 NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />Attending PHYSICIAN
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)Z
<br />March 17
<br />z m
<br />.p0 5 cc
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b.TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />March 23, 2009
<br />23c.TIME OF DEATH
<br />8:13 A. m
<br />8 5' 12
<br />1E:: =
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />23cl. To the best of my k-.wledge, - . th occur ed at th"1rII. e, date and place . w Z
<br />and du to the a --(s) f -. 1..•ature an. 'I ) 7 aO 2 p
<br />i / it P 3J. 3Ioq '8 o
<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 />�•.-�•�':
<br />25. DID TOBAC 0 USE CONTRIBUTE TO THE DEATH?
<br />0 YES VNO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 1i 26b. WAS CONSENT GRANTED?
<br />0 YES VNO 1 Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Robert Hibbard M.D., 1610 South 4:th Suite 600 Lincoln Nebraska 68506
<br />j
<br />!) .I
<br />28a. REGISTRAR'S SIGNATURE 4r
<br />/
<br />I
<br />a 1 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />I MAR 2 7 2009
<br />HHS -61 11'03 (55061)
<br />
|