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,WHEN THIS COPY CAMWS TW RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEK !T COUMS THE BELOW TO SEA TRUE COPY OF THE ORIGINAL_ RECORD ON FLE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS_7= Is <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _ : _ _ <br />DATE OF ISSUANCE <br />NOV 16 1999 COG-rIM <br />200408922 AASIVANt -V 0:1118P tm <br />LINCOLN, NEBRASKA HEALTH ANDU M+AN SERVICES TSW <br />94 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SER FQ1ANCE -_AN ? S_tWORT <br />VITAL STATISTICS <br />rPQTTFTC ATF OF nF.ATH <br />[PART Shr�0.tl Ce k� _ OF �- rmrn�.S <br />I <br />tort <br />Interval between onset and death <br />DUE TO.OR AS A CONSEQUENCE OF <br />m. <br />Interval between onset and death <br />DUE TO OR AS A CONSEOUENCE OF <br />i <br />7 <br />A <br />7 <br />it <br />.tet <br />cl <br />OTHER SIGNIFICANT CONDITIONS Conditions conaibukrtg to the death but nd related <br />I. DECEDENT -NAME FIRST <br />MIDDLE LAST <br />2. SEX <br />3. DATE OF DEATH /Month Day Year) <br />(Ages 10 - No <br />�AL <br />Vera <br />M. Johnston <br />Female <br />November 1 1999 <br />4. CITY AND STATE OF BIRTH kind n OSA.. name country/ <br />5a. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH (Mont.. Day Year) <br />Sb. MOS. DAYS <br />5c. HOURS I MINS. <br />Suicide Pending <br />ryrs.l 72 <br />December 24, 1926 <br />CiIU JCl <br />Holbrook, Nebraska <br />otlice <br />dXc /S� <br />7. SOCIAL SECURTIY NUMBER <br />• <br />Ba. PLACE OF DEATH <br />HOSPITAL: Inpatient OTHER: El Nursing Home <br />508 -26 -6723 <br />- -- - <br />ER Oulpabent E] Residence <br />E] DOA a Other (Sp,,,,,,Skilled Care Ur <br />8b. FACILITY -Name lNnot instAdion. grve street and numb,)) <br />st- Francis Skilled Care <br />Unit <br />7 DATE SIGNED /MO.. Da Yr.l c TIM OF DEATH <br />a a _ <br />i 2Bc. PRONOUNCED DEAD (Mo. Day Yr.l 28d. PRONOUNCED DEAD /Noun <br />95.9 <br />Bc. CITY TOWN OR LOCATION OF DEATH <br />Bd. INSIDE CITY LIMITS Be. COUNTY OF DEATH <br />Grand Island <br />Yee "° ❑ <br />Hall <br />9a. RESIDENCE - STATE 9b. COUNTY <br />9c CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (Inc/udmg Zrp Code) 9e. INSIDE CITY LIMITS <br />1 <br />31 NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI <br />2 N Custer 68803 Yes "° <br />Nebraska <br />aska 68803 <br />marten name) <br />10. RACE - (e.g.. White. Black. American Indian. 11. ANCESTRY <br />leg. Malian. Mexican. German, elcl 12. © MARRIED <br />❑ WIDOWED 13. NAME OF SPOUSE (e wde. give <br />etc.)ISpecifyl (Specify) <br />White <br />T�..,., NEVER <br />Danish MAR IFQ <br />DIVORCED William J. Johnston <br />AL OCCUPATION /Give k/ndci work dome during most <br />14b KIND OF BUSINESS INDUSTRY <br />15. EDUCATION ( Specfy only highest grade completed) <br />Elemen Secondary 1 121 College 114 <br />�l <br />oking life. even Arefired) <br />Teller <br />Bankin <br />1 GraC�ie <br />ER - NAME IRST MIDDLE LAST 17 MOTHER <br />FIRST MIDDLE MAIDEN SURNAME <br />F14a <br />James NMI <br />Anderson <br />Etta NMI Pickering <br />DECEASED EVER IN U.S. ARMED FORCES? <br />� .9- INFORMANT -NAME <br />° or unk.I Id yes. give war and dates d services) <br />I <br />William J. <br />Johnston <br />No <br />_ <br />19b INFORMANT MAILING ADDRESS <br />[STREET OR R. F.0 NO. CITY OR TOWN. STATE. ZIP) <br />23 N <br />20. EMBALMER - SIGNATURE B UCENSE NO ^`` <br />1 <br />/Z j. 21a METNJ00 DISPOSITION 21b. DATE 21c CEMETERY OR CREMA70RV NAME D'y-j� /'��� <br />Removal wn Memorial Park - Ce <br />22a. FUNERAL HOME - NAME \ / <br />21tl. CEMETERY <br />R CREMATORY LOCATION GTV OR TOWN STATE <br />❑ Cremation ❑ Donation <br />Grand Island Nebraska <br />Kleine n 1 <br />__- <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CIT! OR TOWN. STATE. ZPPI <br />3213 W North Front Street-, <br />Grand- Islandf Nebraska 68803 Interval between onset and deam <br />[PART Shr�0.tl Ce k� _ OF �- rmrn�.S <br />I <br />tort <br />Interval between onset and death <br />DUE TO.OR AS A CONSEQUENCE OF <br />m. <br />Interval between onset and death <br />DUE TO OR AS A CONSEOUENCE OF <br />i <br />7 <br />A <br />7 <br />it <br />.tet <br />cl <br />OTHER SIGNIFICANT CONDITIONS Conditions conaibukrtg to the death but nd related <br />PART 111 IF S THERE A <br />PREGNANST 3 MONTHS? <br />AUTOPSY <br />. WAS CASE REFERRED TO MEDICAL <br />AMINER OR CORONER' <br />PART 1 <br />(Ages 10 - No <br />�AL <br />Yes No <br />Yes No <br />26y <br />ATE OF INJURY /Atb. Day. Yc/ <br />26c HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />❑ Accident F1 Undetermined <br />126b, <br />M <br />Suicide Pending <br />26e. INJURY AT WORK <br />261. . )arm. street. factory <br />btOOOt IrgNd�RY <br />26g. LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE <br />otlice <br />dXc /S� <br />Homicide Investgatgn <br />Yes ❑ No a <br />- DATE OF DEATH Mo.pay. Yr.) <br />28a DATE SIGNED /Mo.. Day. YrI 26b. TIME OF DEATH <br />CjLA <br />M <br />7 DATE SIGNED /MO.. Da Yr.l c TIM OF DEATH <br />a a _ <br />i 2Bc. PRONOUNCED DEAD (Mo. Day Yr.l 28d. PRONOUNCED DEAD /Noun <br />95.9 <br />33 ` M <br />�- M <br />g F <br />1M best d my knOwletlgeLd;Z al lime, date an place and due to the <br />28e. On the basis d examination aMor Yrve51KJaI1(xt, m my opinion death occurred at <br />oTo <br />causelsl stated. <br />the time. date and place and due to the cause(S) slated. <br />IS nature and TM4 o nature ttrd Title <br />DID TOGA CO USE CONTRIBUTE TO THE DEATH? HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? AS CONSENT GRANTED <br />YES 0 NO 0 UNKNOWN � <br />YES NO YES NO <br />31 NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI <br />/Type a Print) <br />Kimberly A. Mickels MD'72 Cus <br />aska 68803 <br />32a. REGISTRAR <br />32b. DATE FILED BY REGISTRAR (Mp 0 YTyww <br />NOV 1.0.,1��]/(99 <br />' <br />