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l <br />200311357 <br />Rev 11/97 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND POR 0 Py <br />VITAL STATISTICS <br />C IRMTTIRWATR OF T)FATN <br />O <br />O <br />O <br />T <br />C <br />7 <br />O <br />O <br />O <br />O <br />C_ <br />E <br />to <br />X <br />a) <br />U <br />0 <br />z E <br />W <br />0 E <br />W .° <br />W <br />O L <br />LL t1 <br />O -0 <br />W at <br />Q <br />Z LL <br />I <br />C7 <br />1 i)ECE-DENT -NAME FIRST MIDDLE LAST <br />2. SEX <br />3. DATE OF DEATH (Month Day. Year) <br />Paul Edwin Jackson <br />Male <br />April 27, 2003 <br />4 CITY AND STATE OF BIRTH Ilt not o U SA.. name countryl <br />5a. AGE - Last Binhday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH (Monlh. Day Yearl <br />Des Moines, Iowa <br />Yrsl 74 <br />ISeptember 9, 1928 <br />5h MOS DAYS <br />Sc HOURS MINS <br />7 SOCIAL SECURTIY NUMBER <br />Be . PLACE OF DEATH <br />508 -26 -1449 <br />HOSPITAL. ❑ Inpatient OTHER 1p Nu ,,q Home <br />❑ ER Outpatient El RI <br />8b FACILITY - Name (!/not institution, give street and number/ <br />Wed ewood Care Center <br />❑ DOA ❑ Othe „SPe dy) <br />8c CITY. TOWN OR LOCATION OF DEATH <br />8d. INSIDE CITY LIMITS <br />8e. COUNTY OF DEATH <br />Grand Island <br />Yes a No ❑ <br />Hall <br />27c. TIME OF DEATH <br />9a RESIDENCE - STATE <br />9b COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER !including Zin Code) <br />9e INSIDE CITY LIMITS <br />28e. On the basis of examination and or investigation, m my opinion death occurred at <br />the time, date and place and due to the causels) stated. <br />, (Signature and Title ► <br />Nebraska <br />Hall <br />Grand Island <br />2815 W. Waugh 68803 <br />Yes bd No ❑ <br />32a REGISTRAR <br />10 RACE - (e. g., White. Black. American Indian. <br />11. ANCESTRY 1e. g.. Italian. Mexican, German, etc) <br />12. ® MARRIED ❑WIDOWED <br />13 NAME OF SPOUSE of -/e give made, name/ <br />etc i ISpecity) <br />White <br />(Specdy) <br />American <br />NEVER DIVORCED <br />❑ MARRIED <br />Betty Jean Johnson <br />14a JSUAL OCCUPATION (Give kmdot work done during most <br />14b KIND OF BUSINESS INDUSTRY <br />15. EDUCATION ISpecdy only highest grade completed( <br />of working life, even draft d) <br />Dispatcher /agent <br />Railroad <br />Elementary or Secondar 10 121 College (1 -4 or 5-i <br />li <br />_ <br />16 FATHER -NAME FIRST MIDDLE LAST <br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Osmond Jackson <br />Edith Man_t_hei <br />18 WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT - NAME <br />;Yes no. or unk.) fit yes. gwe war and tlates of services) <br />Yes WWII 1945: -1946 <br />Betty Jackson <br />19b INFORMANT MAILING ADDRESS ISTREET OR R D. NQ., CITY OR TOWN. STATE. ZIP) <br />2815 W. Waugh Grand Island, NE 68803 <br />20 EMBALMER - SIGNATURE 8 LICENSE NO <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c <br />CEMETERY OR CREMATORY NAME <br />Not Embalmed <br />❑ Burial ❑ Removal <br />Ap r i 1 28, 200 <br />Westlawn Crematory <br />220 FUNERAL HOME -NAME <br />21 d. CEMETERY OR CREMATORY LOCATION (,It Y OR TOWN STATE <br />Livingston- Sondermann Fun. Home <br />IC I <br />4 1 °fema " °" ❑ ° °na " °" <br />Grand Island, NE <br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIP) <br />601 N. Webb Rd. Grand Island, NE 68803 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). (b), AND d)) Interval between onset and death <br />PART _ <br />tai "�. L �1..� �Wl.�� e ti \1 l'Llyl a� <br />_I <br />DUE TO, OR AS A CONSEQUENCE OF hl Interval between onset and death <br />fbl <br />.;, DUE CO, OR AS A CONSEQUENCE OF <br />i� <br />I Interval between onset and death <br />I <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />III IF FEMALE. WAS THERE A <br />24 AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />II <br />00­,(X0" <br />IN THE PAST 3 MONTHS? <br />(Ages 10 -54) Yes No <br />Yes Na <br />EXAMINER OR CORONER' <br />Yes No <br />26a <br />26b. DATE OF INJURY /MO.. <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />i j Accident Untletermmed <br />7c <br />M <br />L Suicide Pending <br />_ <br />li homicide Investigation <br />26e. INJURY AT WORK <br />❑ <br />Yes[:] No <br />26f PLACE OF, INJURY - At home, farm. street factory <br />office budding. etc. /Specify) <br />269. LOCATION STREET OR R F D NO CITY OR TOWN STATE <br />27a DATE OF DEATH /M(o`. DDaay. Yr) <br />28a. DATE SIGNED (Mo.. Day Yr.) <br />28b TIME OF DEATH <br />M <br />27b. DATE SIGNED (Mo. Day Yr) <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD (Mo. Day, Yr) <br />280, PRONOUNCED DEAD (Hour) <br />ZZ <br />~ a <br />d i a y <br />~ ° ° <br />27d. To the best of my kno letlge. tleath occurre at he date and place and due to the <br />causels) stated. 1/� <br />(Si nature and Title r ` <br />28e. On the basis of examination and or investigation, m my opinion death occurred at <br />the time, date and place and due to the causels) stated. <br />, (Signature and Title ► <br />III DID TOBACCO USE CONTRIBUT TOT E DEATH? <br />❑ YES ❑ NO UNKNOWN <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CO ERED7 <br />❑ YES NO <br />30.b WAS CONSENT GRANTED'' <br />YES !O / <br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type or Pnnt) <br />Kimberly A. Mickels MD 729 N. Custer Grand Island NE 68803 <br />32a REGISTRAR <br />32b. DATE FILED BY REGISTRAR /Mo.. Day. Yr) <br />FOR VITAL STATISTICS USE ONLY <br />