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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE OR
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL;`
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />MAR 1 2 2007
<br />LINCOLN, NEBRASKA
<br />01 617
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMANS
<br />CERTIFICATE OF DEA
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix) a
<br />Janice Jesse Sloan
<br />SEX > r� .
<br />Female "
<br />*GATE (Mo.,Day,Yr.)
<br />March 1, 2007
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE -Last Birthday
<br />Sb. UNDER 1 YEAR
<br />6c.UNDER.I DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Belleville, Kansas
<br />(Yrs.)
<br />71
<br />MOB.
<br />DAYS
<br />HOURS
<br />MINS.
<br />October 13, 1935
<br />7. SOCIAL SECURITY NUMBER
<br />508-36-3674
<br />8a. PLACE OF DEATH
<br />HOSPITAL: 0 Inpatient Qom: I1 NursingHorne/LTC ❑HOapiceFacility
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />St. Francis Skilled Care
<br />❑ ER/Outpetlent ❑ Decedent's Home_
<br />❑ GOA ❑ Other (Specly)
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />Sd COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall •
<br />9c. CITYOR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />2126 N. Howard Ave.
<br />9e. APT. NO
<br />91. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />X YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH LtMarried 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Leonard Sloan
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Glenn S. Deuel
<br />12, MOTHER'S -NAME (First, Middle, tdeidenSurname)
<br />Neva M. Rice 4
<br />13. EVER IN U.S. ARMED FORCES? Give deles of service if yes.
<br />(Yea, no, Drunk.) No•Leonard
<br />14a. INFORMANT -NAME
<br />Sloan
<br />1 4b. RELATIONSHIP TO DECEDENT.-
<br />Husband
<br />15. METHOD OF DISPOSITION
<br />X�Burial ❑ Donation
<br />❑ Cremation 0 Entombment
<br />ID Removal U Other (Specify)
<br />16a. EMBALMER -SIGNATURE _
<br />/ ��
<br />16b. LICENSE NO.
<br />' 22 3j"
<br />16c. DATE' (Mo., Day, Yr. )
<br />March.6, 2007 ..
<br />16d. CEMETERY, CREMATORY OR OT ER LOCATION CITY / TOWN STATE
<br />Westlawp Memorial Park Cemetery Grand Island, NE
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 West Second, Grand Island, NE.
<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, -
<br />1 7b. Zlp Code
<br />68801
<br />• I. AT!tNTE • - At
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional line If necessary.
<br />IMMEDIATE CAUSE: r I onset to death
<br />IMMEDIATE CAUSE (Final (a) 4r4A.7444 W ( (,t.Lt Comm ie ^' A,94461,
<br />dlseaseorcondldonresulting DUE TO, OR AS A CONSEQUENCE OF: I onsitlo death
<br />Mdeeth) I
<br />Sequentially Ilstconditlons, If (b) I
<br />any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: I onset to dean
<br />online e.
<br />EnterthheUNDERLYINGCAUSE
<br />(dt eeseorinjurythatInitiated (c)
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I onset todeeth
<br />tA3r
<br />03
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />0,4I""S
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTE07
<br />0 YES i' NO
<br />20. IF FEMALE:
<br />Si Not pregnant within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />51 Natural ❑ Homicide
<br />O Accident0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES g NO
<br />0 Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />❑ Suicide ❑ Could not be determined
<br />ID Pedestrian
<br />❑Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At home, farm,
<br />street, factory, office building, construction
<br />site, etc. (Specify)
<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 ZIPCODE
<br />•
<br />�s
<br />23a. DATE OF DEATH (Mo., Day,Yr.)
<br />- 3-1-01
<br />=
<br />ice
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b.TIME OF DEATH
<br />m
<br />_I p.
<br />6
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />3-5 01
<br />23c. TIME OF DEATH
<br />!k's p m
<br />i a-
<br />E `Z
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />M
<br />s
<br />~ <
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />end due to the cause(s) stated. (Signature and Title) ♦
<br />arou, it AA" 49 gyp
<br />85 z O
<br />I p 8
<br />,e
<br />b
<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) V
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES $4, NO ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES p.NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable it 28a Is NO ❑ YES Qg. NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Anne K. Morse M.D. N. Custer Ave., Grand Island, NE. 68803
<br />(729
<br />28a. REGISTRAR'S SIGNATURE /�yL7e�'-w"A1. �•
<br />yl(yY
<br />�r•'sr I'� V
<br />28b. DATE FILED BY REGISTRAR (Mo., Dap, Yr.)
<br />MAR ,- 8-2007
<br />
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