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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANErHUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKADgPAR,TMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR ITAL-REC $,.. •
<br />DATE OF ISSUANCE
<br />AUG 2 6 2008
<br />LINCOLN, NEBRASKA
<br />202003120
<br />STANLEY S. COOPER
<br />‘72.4 SI§TANT STATE RECTI 4'RAR
<br />"„ DEPAkTMENT OF HEALTI±AliD
<br />•. L1MA(N SERVICES ;? '
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINAN.GE �1 U F)
<br />CERTIFICATE OF DEATH •'"'- ' 8 28543
<br />1. DECEDENTS -NAME (First, Middle, Las ,
<br />Jean Phyllis White
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Omaha, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-38-8006
<br />Suffix)
<br />2. SEX
<br />female
<br />5a. AGE -Last Birthday
<br />(Yrs.) 74
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 15, 2008
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />January 30, 1934
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />St. Francis Medical Center
<br />8a. PLACE OF DEATH 7,[
<br />HQSPITBL: OI Inpatient
<br />❑ ER/Outpatient
<br />0 cm
<br />smait 0 Nursing Home/LTC ❑ Hospice Facility
<br />0 Decedent's Home
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island. 68803
<br />8d. COUNTY OF DEATH r "
<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 />1704 Roberta AVe.
<br />9e. APT. NO
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />t YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH aMarrIed 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME
<br />William
<br />OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />G. White
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Lester Meisinger
<br />12. MOTHER'S -NAME (First, Middle, eiden Surname)
<br />Adelia TTrAtch
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service 4 yes.
<br />(Yes, no,orunk.) No
<br />14a. INFORMANT -NAME
<br />William
<br />G. White
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />15. METHOD OF DISPOSITION
<br />❑Burial ❑Donation
<br />168. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr. )
<br />8/15/2008
<br />Iti Cremation 0 Entombment
<br />aRemoval ❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska
<br />CITY / TOWN STATE
<br />Cremation Service Gibbon, NE
<br />LAll
<br />17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, State)
<br />FAiths Funeral Home, 2929 S.
<br />18. PART I. Enter the chain of events --diseases, injuries, or complications --that directly caused
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATECAUliE(Flnal (a)
<br />0 t�. tE,4(L0 t/ C. -t4 Wt.
<br />Locust St., Grand Island,NE
<br />the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE
<br />Enter only one cause on a line. Add additional lines if necessary.
<br />onset
<br />A-Ccr� Dv (
<br />176 Zin f nde
<br />68801
<br />INTERVAL
<br />to death
<br />.2
<br />disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF:
<br />In death)
<br />t� -f
<br />Sequentially list conditions, 1 (b)
<br />any, leading to themes Heed
<br />I onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />i on lines.
<br />Enter t* UNDERLY*IG CAUSE
<br />(disease or Injury that Initiated (0)
<br />theevents resulting in death)
<br />onset to Beeth
<br />DUE T0, OR AS A CONSEQUENCE OF:
<br />LASTI
<br />(d)
<br />onset to death
<br />r };! 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not
<br />I A41 / `r /1 t.„1 �fl j// Ait
<br />resulting in the underlying cause given in PART I.
<br />/ RQ/ / a%' �' S f/
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />CI YES ANY
<br />`4. 20. IF FEMALE
<br />pi Not pregnant within past yearP
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />❑ Natural 0 Homicide
<br />0 Accident0 Pending
<br />Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />erator
<br />❑Passe nger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES I;(60
<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 />0 Unknown if pregnant within the past year
<br />0 Suicide 0 Could 001
<br />be determined
<br />0 Pedestrian
<br />❑Other (Specify)
<br />21d WERE AUTOPSY FINDINGS AVAtLABLE 10
<br />COMPLETE CAUSE OF DEATH?
<br />0 YES ierNO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />x<.
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY
<br />-At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OFINJURY - STREET & NUMBER, APT. NO. CITY/TOWN
<br />SWE ZIP CODE
<br />>'£sa
<br />g
<br />v
<br />23a. DATE OF DEATH(Mo., Day,Yr.)
<br />August 1?..,
<br />5, 2008
<br />z
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b.TIME OF DEATH
<br />m
<br />y
<br />�•. .gi
<br />23b. DATE SIGNED (Mo., Day, Y,I.
<br />�l- I �"-o
<br />23c.TIME OF DEATH
<br />07:00 A.m
<br />I >
<br />e
<br />ad<II
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />0
<br />o e
<br />2 zr(`
<br />23d.To the best y knowledge athjjjgggoccurred
<br />and due a euae(�st (S ne
<br />at the time, date and place
<br />d Title )
<br />w
<br />o 2g3
<br />Qb
<br />24e. On the basis of examination and/or investigation,
<br />the time, date and place and due to the
<br />in my opinion death occurred at
<br />cause(s) stated. (Signature and Title •
<br />)
<br />-�w 25. DID TOBACCO USE CONTRIBUTETOTHE DEATH?
<br />i�.
<br />0 YES AI& 0 PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YESO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO 0 YES �NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUN ORNEY) (Type or Print)
<br />David Colan, M.D., 729 N. Custer Ave., Grand Island, Nebraska 68803
<br />avita
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />AUG 2 2 2008
<br />
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