200407521 - Laserfiche WebLink

Browse

WREN '}NS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORp ON PXE1Nl K THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEC;T1GAf,- WF*CK1$ _ THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE NOV 5 2002 2 0 0 4 0 7 5 21 ASSISTANTSTAATEREG STRAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE ANDSUPPORT VITAL STATISTICS _ _-:0 2- .12547 CFRTIFICATF, OF DEATH -- 1. DECEDENT NAME FIRST MIDDLE LAST 2. SEX 3. DATE:UrDEATH tMomh. Day Year) Mary Genevieve Yount Female October 7, 2002 4, CITY AND STATE OF BIRTH /t1 not in USA.. name Country] 5a. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /MOnb). Day. Year/ MOS DAYS Sc. HOURS MINS Hastings, Nebraska (YrsI 58 5b February 9, 1944 7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home 505 -56 -7241 ® ER Outpatient ❑ Residence 8b. FACILITY - Name ty not institution. give street and number) St. Francis Medical Center ❑ DOA ❑ Other/$peoh, 8c CITY TOWN OR LOCATION OF DEATH 8r). INSIDE CITY LIMITS 8e COUNTY OF DEATH Grand Island yes ❑% No ❑ Hall 9a. RESIDENCE - STATE 9b COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /Including Zip Code/ 9e INSIDE CITY LIMITS Nebraska Hall Grand Island 1005 N. Sherman 68803 Yes ® No ❑ 10. RACE - (e.g., White. Black. American Indian 11. ANCESTRY le g_ halian. Mexican. German. etc) 12. ® MARRIED ❑ WIDOWED 13 NAME OF SPOUSE /it wile. give maiden name/ etc.) 1Soecify1� (Specldl I American NEVER DIVORCED James V. Yount Sr. hite MARRIED 14a. USUAL OCCUPATION (Give kindot work done dining most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specu[y only hghest grade completed) Elementary ^ Secondary 10 -12) College n -4 01 5-1 of working lire, even if retired) Sales/Bookkeeper Lukas iewicz Furniture 1L 16. FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Max Moore Margaret Rosser 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT -NAME (Yes�r wr unk.) III yes. give war and dates of services) jL�VJ James Yount Sr. 19b INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP( 1005 N. Sherman, Grand Island, NE 68803 . EMB MER - SIGNATURE 8 LICENSE NO. 9j 3 p 3 r 21 a. METHOD OF DISPOSITION 21b. DATE 21 c. CEMETERY OR CREMATORY NAME 7 Q / Burial ❑Removal Oct. 11, 2002 Westlawn Memorial Park 22a. FUNERAL M - NAME 21d CEMETERY OR CREMATORY LOCATION CI7v OR TOWN STATE Apfel- Butler- Geddes ❑Cremation ❑Donator Grand Island, NE. 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) 1123 West Second, Grand Island, NE. 68801 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR ial. (bl. AND IC)) I Interval between onset and dealt, PART (al Myocardial infarction DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death I i lb) DUE TO.OR AS A CONSEQUENCE OF -. 1 Interval between onset and death I I (p) I OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but nol related PART ul IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER' II (Ages 70 -54) Yes No Vey No Yes No 26a. 26b. DATE OF INJURY /MO.. Day Vc) 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident F] Undetermined M Suicide F� Pending 26e. INJURY AT WORK 26f. PLACE OF INJURY - At home. [arm, street. factory 269 LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE InvestgatOn ❑ ❑ o ice budding. etc iSpecily/ HomiaOe yes NO 27a. DATE OF DEATH /Mo. Day Yr.) 28a. DATE SIGNED !Mo.. Day. Yr.) 28b TIME OF DEATH >3Q Ct0 M N < 27b. DATE SIGNED /Mr)_ Day. Yi.l 27c. TfME OF DEATH 28c. PRONOUNCED DEAD /Mo. Day. Ycl 28d. PRONOUNCED DEAD /noun y } -wig °€� g M g � Ct0 M F z 0 o ° 27d. To the best of my knowledge. tl occ r at the fime. date and place and due to the 28e. On the basis of examination and oryNestgaton, in my opinion death occurred at cause(sl stated. ) the time. date and place aid a uselsl stated. t / ISi nature and Title ISi nature and Title 29 DID TOBACCO USE CONTRIBUT O THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b A T GRANTED' At ty ❑ VES NO KNOWN ® VES ❑ NO 12 VES El NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or Prim) Mark J Young Chief Deputy Hall Co Att 117 E 1st Grand Island, 14E 6881 32a. REGISTRAR 32b DATE FILED BBY REGISTRAR IMp6Z YI./ i Z jU' (`J] w ' %l )l