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<br />STATE OF NEBRASKA
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<br />HEN TI/S COPY .::40•00S THE'RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO •
<br />BEA TRUE OOPy OF THE ORIGINAL.RECORD ON FILE WITH TKE NEERASKA DEPARTMENT OF HEALTH AND
<br />UMAN.';SERVICgS, VITAL. RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS .
<br />E ATE (7F 7S3ttANG
<br />6/28/2022
<br />INCOLN' NEBRAS
<br />202205242
<br />144-1
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAI
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1 DECEDENT &NAME (Filet �Aidd{e;:, Last . , Suf lx)
<br />John Jeiph Pascoe
<br />/
<br />RY,,OR FOREIGN COUNTRY OF BIRTH
<br />B CITY AND S`T'ATE OR tERRITO
<br />feb'I ht;Niebra
<br />Socia tealR1V
<br />5W8-.1426,
<br />U
<br />ER;
<br />1TY.N. ME Af: not: tnstt
<br />Sint Franel>s Medical Center'
<br />treet end.number)
<br />8c;
<br />OR Tt t43iN OP DEATH {ktctude zip Code)
<br />Tait ,888Q
<br />9 .;RE8IDONCE-S'tAT
<br />Natal$ aka>:., ..;:;.
<br />Sa AGE - Last Birthday`
<br />(Yrs.)
<br />5b:UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />Ba.:PLACE OFiDEATH
<br />HOST RiTAL I4 tnp tietht
<br />❑ ER/Outpatient
<br />PQA.
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS.
<br />MINS.
<br />OTHER 0 Nursin
<br />❑ Doted
<br />❑ Other (Specify)
<br />3. DATE DFA1M (PI(P > Dap Yl
<br />March3O,.2112'.!
<br />9b. COUNTY
<br />Hall
<br />8c. CITY OR TOWN
<br />Grand island
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9. S7I*ET'ANE?N9OBBN ;,
<br />51:2 VI(phde rllx
<br />106. MARttAL $tATUB ATT
<br />Married .but separates
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />OF DEATH ® Married 0 Never Married
<br />Widgwed ❑' Divorced 0 Unknown
<br />IN
<br />,'(Yei
<br />'la:.M*THOR•Off
<br />Burial ❑ Dbt+a#)4
<br />unls
<br />CES? Give.dates of service if Yes.
<br />unknown -09/15/1977
<br />1Ta t UNEEA# #i
<br />AI} Faiths O .
<br />1Qb. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give inside
<br />Shirley Noziska
<br />14a. INFORMANT -NAME
<br />Shirley Pascoe
<br />6e. EMBALMER -SIGNATURE
<br />Matthew T. Myers
<br />12„M(OTHER'SN.AME (First,
<br />Marilyrt Gilligan.
<br />1$c!: CEMETERY, CREMATORY OR OTHER LOCATION
<br />Vllestlawn Memorial Park Cemetery
<br />16b. LICENSE NO.
<br />1411
<br />AND .MAILING ADDRESS (Street, City or Town, State)
<br />te,2929 S. Locust Street, Grand Island, <Nebraska
<br />Middle,
<br />CITY ITOWN
<br />Grand Island.
<br />14b. RELA
<br />Wlf6r..: '.
<br />160. DATE
<br />:. A)arit
<br />D
<br />NT:
<br />aTAT1�' ,
<br />CAUSE F DEATH (See'€nstrLtetions and examples)
<br />EMeT the eI•'' • of e'venta { tseesas, injAirles, or complications -that directly caused the death. DO NOT enter terminal events such es cardiac arrest,
<br />tegry airesy p tvahtrlcutar #Nriaatidn without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines N necessary.
<br />:IMMEDIATE CAUSE:
<br />r Atlee llrlarB) Coronary Atherosclerosis
<br />ORAS A CONSEQUENCE OF:
<br />ole
<br />DUE; T3
<br />AS A CONSEQUENCE OF:
<br />CONDITIONS -Conditions contributing to the death but net resut(in
<br />SI If FEMA
<br />Nat Pregq
<br />Q
<br />thin 42. daps of:death.'
<br />43 nape tot year before death
<br />:Ptlst.Year
<br />o.;13ay,
<br />22s`f DESC
<br />`470. Z1#t^
<br />6880
<br />underlying cause given. In PART I.
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Hotmolde
<br />❑ Accident ❑Pending fnvsstigaUon
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. pL
<br />IBE HOW INJURY OCCURRED
<br />2'00F:TRANSPORTATION INJURY'
<br />1 tadver/operator
<br />.❑ Paesenger
<br />Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN. AU
<br />®.'%res
<br />ED?
<br />21d `WERE AUTOPSY PINOING8AV •
<br />fO COMPLETE CAUIIE O,DEA'
<br />®`YES CI IVO
<br />E OF INJURY At home /farm, street, factory, office build'
<br />ETA' NUMBER, APT.NO.
<br />23b DATESIG#4En (a
<br />, Diy, Yr.)
<br />CITY/TDMIN
<br />23c. TIME OF DEATH
<br />iy knewtedge, death occurred at the time, date and place
<br />suse(s)atated:isignature and Title)
<br />3b<:Dlf R f`t
<br />•
<br />0 YEs
<br />27 ¢jAME,'TIY'i,:E AND A DDRESS OP CERTIFIER (Type or Print
<br />Gall V/erSlaas, Heil,DeputyCounty Attorney, 231 S. Locust, P.O. BOX 367, Grand Island, Nebraska, 68802
<br />Il'dUTE TO THE DEATH?
<br />PROBABLY ®UNKNOWN
<br />STATE
<br />DE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />April 3, 2012
<br />24cPRONOUNCED DEAD (Mo; Day, Yr.)
<br />i'iNititdh 30.'2012
<br />24b: TIME OF DEATH.
<br />App122.:2]
<br />24d. TIME`f<UN?
<br />12:42 PM...'
<br />24e On the Oasis of examination and/or investigation, in�my. len death d
<br />?the ttnie, date and place and due to the cause(s) stated. (signature snit:
<br />Gail VerMaas, Hall Deputy County Attom
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />26b. WAS CONSENT
<br />Not Applicable If 2621
<br />28e.:REGISTRAR'S SII
<br />uRE4e, A
<br />28b. DATE -FILED ay REG ISTRAR (M
<br />April 5, 2012
<br />Day
<br />
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