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WHEN THIS COPY CAMWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND "M SERVICES <br />SYSTEM, RCERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGW4BVC M ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAUXk_$�_E0 Yft_ WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />wr <br />DATE OF ISSUANCE <br />-` <br />A DOPER <br />11/18/2004 200411780 x - - <br />: Asars�ANTST�1. _ tRAR <br />LINCOLN, NEBRASKA HEALTi44 YQj1F SYSTEM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH ANDlAl%iCE AND SUPPORT <br />VITAL STATISTI&g <br />CFRTTFiCATF OF DEATH f) A n1 'I a (1 <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />-2. SEX - .- -. <br />3. DATE OF DEAT ( onM. Da . Y <br />William M. Feurt Jr. <br />Male <br />January 24, 2004 <br />a. CITY AND STATE OF BIRTH X not in USA.. name country) <br />5a. AGE -Last Bi thday • <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />16. DATE OF BIRTH (Monts. Day. Year) <br />MOS. DAYS <br />Sc. HOURS' MIN'. <br />Hastings, Nebraska <br />(Yrs.1 5b. <br />53 <br />November 6, 1950 <br />T SOCIAL SECURTIY NUMBER <br />Ba. PLACE OF DEATH <br />508-60-2380 <br />HOSPITAL: Inpatient OTHER: ❑ Nursing Home <br />❑ ER Outpatient ❑ Residence <br />8b. FACILITY - Name (ff not institution, give street and number/ <br />VAMC, Omaha, Nebraska <br />❑ DOA ❑ Other(Specfyr <br />Sc. CITY. TOWN OR LOCATION OF DEATH <br />8d. INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Omaha, Nebraska <br />Yee ® No F-1 <br />Douglas <br />9a. RESIDENCE - STATE <br />9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER /Including Zip Code) <br />9e. INSIDE CITY LIMITS <br />Nebraska <br />- Hall <br />Al da <br />607 Saturn St. <br />Yea E No ❑ <br />10. RACE - (e.g, White. Black. American Indian. <br />11. ANCESTRY (e.g.. Italian, Mexican, German, etc( <br />12. ® MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE (If wife. give maiden name) <br />etc.) (Specify) <br />whi a <br />(Specify( <br />NEVER DIVORCED <br />MAR 1 <br />Verna S m i t h <br />14a. USUAL OCCUPATION /Give kind of work done during most 14b. <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specify only highest grade completed) <br />Elementary or Secondary (0 -12) College (1 -4 or 511 <br />of working life, even if retired/ <br />U.S.Army <br />Military <br />2 <br />16. FATHER -NAME FIRST MIDDLE LAST 17. <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />William M. Feurt Sr. <br />Joyce Pedersen <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />Be. 1 INFORMANT -NAME <br />(Yes. no. or unk.) in yes. give war and dates of services) <br />Yeas Vi tna - 5 25/71-5/31/91 <br />Verna Feurt <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE ZIP) <br />607 Saturn Street Alda NE 68810 <br />20. MER - GNATURE 8 ENSE NO. <br />21 a. METHOD OF DISPOSITION <br />21b. DATE - <br />c. CEMETERY OR CREMATORY - NAME <br />❑Burial ❑Removal <br />721 <br />1/27/2004 <br />Forest Lawn Cremator <br />22a. FUNERAL HOME - NAMP <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />John A. Gentleman <br />11 Clefflahon ❑Donsuon <br />Omaha NE <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP) <br />1010 N. 72nd Street Omaha NE 68114 <br />23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lab (b6 AND (c)) Interval between onset and death <br />PART I <br />I Arrest Minutes <br />)a, Cardiac <br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death <br />)b) Respiratory Failure Days <br />DUE TO, OR AS A CONSEQUENCE OF: In2cna ......roen cIcat and d.,a.,. <br />I <br />)c) <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />III IF FEMALE WAS THERE A 24 <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER? <br />II <br />(Ages <br />10 -541 Yes No <br />Yes .NO <br />Yes NO <br />26a. <br />26b. DATE OF INJURY (Mo.. Day. Yr) <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />Accident Undetermined <br />M <br />❑ Suicide r Pending <br />260. INJURY AT WORK <br />26f. PLACE OF.INJURY - h�, farm, street factory <br />office builds <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />Yes ❑ No ❑ <br />27a. DATE OF DEATH (Mo.. Day. Yr.) <br />28a. DATE SIGNED (Mo.. Day. Yr) <br />28b. TIME OF DEATH <br />�< <br />January 24, 2004 <br />M <br />27b. DATE SIGNED (MO.. Day. Yrl <br />27c. TIME OF DEATH <br />i < y <br />28c. PRONOUNCED DEAD (Mo.. Day, Yr.j <br />28d. PRONOUNCED DEAD (Hour) <br />January 24 2004 <br />2:30 P.M <br />$'z <br />M <br />27d. TAI e best of my kno ledge. death occurred at the time, date and place and due to the <br />ousels) trued. <br />° � 0 28s. On Me basis of examination andror investigation, in my opinion death occurred at <br />~ ° o Me time, date and place and due o the cause(s) stated. <br />�j3 <br />nalre and T e) <br />I$ <br />, (Signature and Title) ► <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a <br />HAS ORGAN OR TISSUE DONATION CONSIDERED? 30.6 <br />WAS CONSENT GRANTED? <br />❑ YES El NO 7x UNKNOWN <br />IBEEEEN <br />E] YES IV I NO <br />❑ YES IV I NO <br />7t' <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type a Prinnttj <br />Sudha R. Ravilla M.D. VA Medical Center, 4101 Woolworth Ave. Omaha NE 68105 <br />32a. REGISTRAR ,.s/" <br />32b. DATE FILED BY REGISTRAR (MO.. Day. Yr.) <br />2 �,� <br />JAN 2 7 2004 <br />