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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HBALTHAND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />MAR 3 0 2006
<br />LINCOLN, NEBRASKA
<br />exe-
<br />CSTANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />HEALTH AND HUMAN SERVICES
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT-
<br />• ( DTICIA+ATC Ae, rt .
<br />20250496
<br />-•..... v.. v.- ...ern
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Thendnre Neorlis amaon
<br />2. SEX
<br />Male
<br />lJD r airi,q
<br />3. DATE OF DEATH (Ma, Day, Yr.)
<br />March 14. 2006
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5.. AGE -Last Birthday
<br />5b, UNDER I YEAR
<br />Sc. UNDER / DAY
<br />S. DATE OF BIRTH (Mo., Day, Yr.)
<br />Boulder, Colorado
<br />' (Yrs.) 79
<br />MOE.
<br />DAYS
<br />HOURS
<br />MINS.
<br />October 8, 1926
<br />7. SOCIAL SECURITY NUMBER
<br />5 0 6- 20- 5 3 7 6
<br />San PLACEOF DEATH
<br />HQSEEAL' di Inpatient MS ❑ Nur.eg ❑
<br />t -
<br />7"
<br />eb. FACILITY -NAME (II not Inetllullon, give street and number)
<br />S t . Francis Medical Center
<br />Home/LTC Howice,FedSry
<br />❑ ERIOulpstbnt ❑Decedent's Hems
<br />❑ DX ❑ OHier(dpedly)
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Sri. COUNTY OF DEATH
<br />Hall
<br />ea. RESIDENCE -STATE
<br />Nebraska
<br />Ph COUNTY
<br />Hall
<br />.a CITY OIITOWN
<br />Grand IslandPd.
<br />STREET AND NUMBER
<br />2004 W. Anna
<br />Pe. NO
<br />Of.ZIP
<br />Sp.YyINSIDE CITY LIMITS
<br />MI YES ❑ NO
<br />5 � ,
<br />,y(
<br />10e. MARITAL STATUS AT TIME OF DEATH CXMarried ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />15b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name.
<br />Anne J o u r a s
<br />I I. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />t>t Nick Jamson
<br />12. MOTHER'S -NAME (First, - Middle, Maiden Surname)
<br />Elizabeth, Joratz
<br />(YEVER IN U.S. ARMED FORCES? Give dales of service Ifyes.
<br />(Y.eoorunka11/8/44-7/13/46
<br />14a. INFORMANT -NAME
<br />Anna Jamson
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />1:1Burial ❑Donation
<br />15..E LMER-SIGNATU
<br />( � V..ut3r
<br />LICENSE NO.
<br />ISb. 1328
<br />ISo. DATE (Mo., Day, Yr.)
<br />March 17, 2006
<br />❑Cremation ❑Entombment
<br />❑Removal ❑Other(Specify)
<br />lad. GENET Y, CREMATORYOAbrHER LOCATION CITY/TOWN STATE
<br />Westlawn Memorial Park Cemetery, Grand Island, Nebraska
<br />17a FUNERAL HOME NAME AND. MAIL NG ADDRESS (Street, City or Town, Stale)
<br />l
<br />aiths FuneraHome,2929 S. Locust St. Grand Island, NE
<br />PART I. Enter the ahalnelevent.--dIses.eu injuries, orcomplkNbns-that directy auead IM death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Erdaronly onem.. on a line. Add additional lines if necessary.
<br />IMME
<br />IMMEDIATE CAUSE (Final
<br />disease orcondition
<br />/eaitkp
<br />in death)
<br />Seganthlly Bet conditional'
<br />any, leading Io uM awns Slid
<br />on lie...
<br />Ever the IRIDERLYW G CNISE
<br />(dismiss or In(urythan mhfated
<br />the owls 'sculling mMeth)
<br />LAST
<br />CAUSE:
<br />w(434
<br />8
<br />APPROXIMATE INTERVAL
<br />onset to deal
<br />DSF'FO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />N
<br />onealmdeilh / .
<br />onset to deaH1
<br />IS. P II. OTHER SIGNIFICAN ONDITIONS-Conditb5. contributing to the Ih but nod matting In lb. underlying cause given M PART I.
<br />�,� 1 I
<br />20. IF FEMALE:
<br />O Not pregnant within past year
<br />❑ Pregnant at Ilm. of death
<br />❑ Not pregnant, but pregnant within 42 days of deem
<br />❑ Not pregnant, but pregant43days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />2i.FNER OFD '!1
<br />Nahrrel ❑HaticMe
<br />22b. TIME OF INJURY
<br />❑ Accident❑ Pending Investigation
<br />❑ Suidd. ❑ Could not be determined
<br />suet to death
<br />21A IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑Passenger
<br />❑ Pedawan
<br />00MINISPecIM
<br />IS. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES .y NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES H1Bo
<br />21Q WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CMJSE OF DEATH?
<br />❑ YES 4.
<br />22c. PLACE OF INJURY -Al lame, farm, street, factory, aGoe building, construction sits, etc. (Sp
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY • STREET 5 NUMBER, APT. NO.
<br />CRY/TOWN
<br />EDGE ZIP CODE
<br />23a. DATE OF DEATH (Ma, Day, Yr.)
<br />March 14, 2006
<br />230, SIGNED (Mo., Day, Yr.)
<br />[fear 15,2006
<br />3d. To the of my
<br />and a Id the aue
<br />22TIME OF
<br />m
<br />oath occur ed et the time, dale and place
<br />(Signature end Title ) •
<br />25.DIDT BAC,CO USE CONTRIBUTE TOTHEDEATH?
<br />❑ 11FS/ NO ❑ PROBABLY ❑ UNKNOWN
<br />24e. DATE SIGNED (Mo., Day, Yr.)
<br />24b.TIME OF DEATH
<br />m
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />24. On the basis of examination and/or mvestpation, m my opinion path occurred at
<br />the time, GM and place and this to to came(s) slated. (Signature end retie I •
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ❑
<br />27. NAME,TITL AADADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY NEY)(1)peor pint)
<br />John A. Wagoner, M.D., 800 Alpha St. Grand Island
<br />28a. REGISTRAR'S SIGNATURE
<br />,(iketto (opt,
<br />2Sb. WAS CONSENT GRANTED?
<br />Not Applicable II 2Ra Is NO ❑ YES 1160
<br />Nebraska 68803
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />MAR 3 0 2006
<br />
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