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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AN
<br />771E BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA rep
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS 771E LEGAL DEPOSITORY FOR VITAq
<br />DATE OF ISSUANCE
<br />04/14/2011
<br />LINCOLN, NEBRASKA
<br />202304644
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES' *' • tI
<br />CERTIFICATE OF DEATH r
<br />To be completed/verified by: FUNERAL DIRECTOR
<br />1
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />George Harlan Ferris
<br />2. SEX ; ,'3:
<br />Male
<br />blittOdEraitpilk, Day;w4
<br />' April 9i 201 "
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE • Last Birthday
<br />Bb. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />6. DATE OF BIRT41(IIIb,, Day, Yr3
<br />Archer, Nebraska
<br />(Yrs.)
<br />83
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />December 6, 1927
<br />7. SOCIAL SECURITY NUMBER
<br />508-40-2553
<br />8a. PLACE OF DEATH
<br />MEW& ❑ Inpatient QTS 0 Nursing HomOILTC ❑.*mi'ce Facility
<br />(lb. FACILITY -NAME (If not Institution, give street and number)
<br />Saint Frands Medical Center
<br />® ERIOu tpatlent 0 Decedent's Home
<br />1 DOA 0 Other (Specify)
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />lid. 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 />3119 W Faidley Avenue
<br />9e. APT. N0.
<br />B. ZIP CODE
<br />68801
<br />Sg. INSIDE CITY.UMITS
<br />0 "YES Q ' NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffbc) If wife, give maiden name
<br />Kathryn Lea Bonness
<br />11. FATHER'S -NAME (First Middle, Last, Suffix)
<br />Lee James Ferris
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Eva Hathaway
<br />13. EVER IN U.S. ARMED FORCES? Give dates of smvlce If Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Kathryn Lea Ferris
<br />14b. RELATIONSN-W 1O DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />19a. EMBALMFR.SIGNATURE
<br />Trent Wagner
<br />19b. LICENSE NO.
<br />1257
<br />19c. DATE (Mo., Day, Yr.)
<br />April 144, 2011
<br />® CremMl°n 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City/ or Town, State)
<br />Wagner Funeral Home, 1702 31st St., Central City, Nebraska
<br />17b. Zip Code
<br />68826
<br />CAUSE OF DEATH (See instructions and examples)
<br />z
<br />F
<br />tttt-
<br />k❑
<br />F
<br />12
<br />48. PART I. Enter the abaj» of events. -diseases, injuries, or complIweons-that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPRO)SMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showhrg the etiology. DO NOT ABBREVIATE. Enter only one cause on a Zine. Add additional Imes if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Acute Cardiac Arrest
<br />disease or condition resulting
<br />onset to death
<br />30 Minutes
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially eat condalons, I b) Diffuse Cardiac Vascular Disease
<br />any, leading to the cause listed
<br />One
<br />onset to death
<br />Chronic
<br />on a. DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE e)
<br />(disease or Injury that Initiated
<br />onset to death
<br />the treats resulting 10 death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDMONS-Conditlons contributing to the death but not resulting In the underlying cause given In PART L
<br />19. WAS MEDWALEXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES/ / NO
<br />20. IF FEMALE:
<br />0 Not pregnant within pant year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSYPERFORMED?
<br />❑ YES ®NO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />Not pregnant but pregnant 43 days to 1 year before death
<br />0 Unknown N pregnant within the past year
<br />Suicide Could not be dstennined
<br />❑ ❑
<br />0 Pedestrian
<br />0 Other (Speolfy)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE QF DEATH?
<br />0 YES ■ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home,
<br />farm, street, factory, office building,
<br />construction site, etc. Owlet)
<br />22d. INJURY AT WORK?
<br />❑YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE Z)P CODE
<br />a' s
<br />23a. DATE OF DEATH ono, Day, Yr.)
<br />April 9, 2011
<br />i
<br />1
<br />24e. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />v
<br />i ).23b.
<br />8 6 =
<br />DATE SIGNED (Mo., Day, Yr.)
<br />April 12, 2011
<br />23c. TIME OF DEATH
<br />07:45 PM
<br />i
<br />Ia. at
<br />a
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONG DEAD
<br />To the best of my knowledge, death occurred at the time, date and place
<br />and due tothe cause(s) stated. (Signature and Tse)
<br />Richard Fruehling, MD
<br />$ i i
<br />8 1
<br />t, it
<br />24e. On the its of examlnallon eedlor investigation, in my opt lea dei oaeawed at
<br />the lime, date and pace and dire to the Cause( Stated. (Sig and ultte3
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES N NO 4 PROBABLY JJ UNKNOWN
<br />28a. HAS ORGAN OR TISSUE
<br />0 YES
<br />DONATION BERN CONSIDERED? tib. WAS CONSENT GRJNtTIEO?
<br />No Not Applicable ff 28a is NO 0 YES ❑ NO
<br />7. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYBICFAN ASSISTANT, CORS PHYSICIAN OR COUNTY AT'bRNEY) (Type or PrinQ
<br />Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIIGNATURE, 4
<br />j28b. DATE FILED BY REGISTRA Io , Day, W.)
<br />I April 12, 2011
<br />
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