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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND NUM4N,S,gRVIDES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BEA TRUE COPY OF THE ORIGINAI. RECO? ,9N FLLE''WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI$TI9S\SECTIP,1(1;'W-1101 1S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />JUN 1 8 Z008
<br />LINCOLN, NEBRASKA
<br />201Su7775
<br />TANLEYS. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />HEALTH AND HUMAN SERVICES,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AN HUMAN SERVICES
<br />( FRTIFICOTF CIF 11FOTH
<br />To Be CompletedNerified by: FoPFRAI. OIR CTOR .J I
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Jerry Eugene Thorne
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo.,Day,Yr.)
<br />June 10, 2008
<br />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 />Grand Island, Nebraska
<br />(Yrs.)
<br />77
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />September 27, 1930
<br />7. SOCIAL SECURITY NUMBER
<br />507-32-6365
<br />8a. PLACE OF DEATH
<br />HOSPITAL' ® Inpatient OTHER: ❑ Nursing Home/LTC ❑ Hospice Facility
<br />Bb. FACILITY -NAME (If not Institution, give street and number)
<br />Saint Francis Medical Center
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA ❑other(specify)
<br />6c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />Id. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9e. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1508 South Sylvan
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® Yes 0 No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) I wife, give maiden name.
<br />Beverly A Thorne
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Hans Fredrick Thorne
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Katherine Gesekinq
<br />13.VEVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(ie IYo, or Unk.) 9 / 1 8 / 51 - 6 / 1 7 / 5 3
<br />14a. INFORMANT -NAME
<br />Beverly A Thorne
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />❑B°`lel ❑D°n.ti°"
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />June 11, 2008
<br />®cremation ❑Entombment
<br />❑Removal ❑OIhaRSlrocify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the g65LD.gf events - mseasss, Incudes, or complications- that directly caused the death. Do NOT enter terminal events such as cardiac arrest, i APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional Imes if necessary.
<br />IMMEDIATE CAUSE: I onset to death
<br />IMMEDIATE CAUSE (Final e'n F . ynf I
<br />disease or condition resulting a) � / Ct a / {.� C i \ ,
<br />. ,Q , t 0 I
<br />In death) CCC���iii �-�l L 1, l/V O -ISGi V ��Ul t•�'�JS+
<br />�
<br />DUE TO, OR AS A CONSE ENCE OF: l onset to death
<br />I
<br />Sequentially list conditions, If b) I
<br />any, leading to the cause listed
<br />on line a. I
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />I
<br />Enter the UNDERLYING CAUSE c) 1
<br />(disease or Injury that initiated I
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST I
<br />I
<br />d) I
<br />18. PART 11. OTHER SIGNIFICANT CON ONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />Urxt. \t Xt7>✓ 'l `t
<br />t
<br />19. WAS MEDICAL EXA NER
<br />OR CORONER CON TED?
<br />❑ YES NO
<br />20. IF FEMALE: 1
<br />910ot pregnant within past year
<br />21a. MANN OF DEATH l
<br />e'IQatural ❑ Homicide
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES glib
<br />❑ Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unknown If pregnant within the past year
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES °Or
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22e. PLACE OF INJURY -At home, fans, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES plitir
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />.0-
<br />23a. DATE OF DEATH (Mo., Day, Yr.)Z
<br />June 10, 2008
<br />a uz
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />di rn
<br />121E.>.
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />June 12, 2008
<br />23e. TIME OF DEATH
<br />3:53 p.m.
<br />S } 0
<br />).-
<br />Ey<o
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />ro v
<br />oand
<br />FQ
<br />st of my kno e e, death occurred at the time, date and place J W z24e.
<br />duet the cause( ) st ed. (Sign lure dtle) O2 g8
<br />t'i( FOU
<br />10 �Ct Jj 0`o
<br />On the basis of examination and/or investigation, in my opinion death occurred
<br />at the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />y�5. DD TOBACCO US CONTRIBUTE TO THE DEATH?
<br />�j'.YES 0 NO ❑PROBABLY ❑UNKNOWN
<br />28a. HAS ORGAN OR r • r N BEEN CONSIDERED?
<br />0 YESNO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO 0 YES
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTYATTORNEY) (Type or Print)
<br />Ryan Crouch, D.Oe, 800 Alpha St., Grand Island, Nebraska 68803
<br />P
<br />281. REGISTRAR'S SIGNATURE ,(
<br />� L
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JUN 1 R 2nnR
<br />
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