|
Z O H
<br />CD
<br />P o tjj
<br />rn c+ P
<br />o 13
<br />y
<br />tV m
<br />0
<br />N• r�
<br />o ca
<br />C ''b
<br />0 (D
<br />�3 m
<br />P +
<br />C
<br />�• o
<br />m
<br />Ct
<br />P t'
<br />0
<br />U c+
<br />c
<br />H. O
<br />C
<br />cn t�
<br />H• �
<br />O
<br />� P
<br />r•
<br />C
<br />O
<br />C
<br />C: N
<br />H. to
<br />C, m
<br />O C
<br />L7 'G
<br />i-•
<br />Cn r>
<br />w r.
<br />p
<br />C+
<br />WHEN TM COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FA-E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEC IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />"-ANLEYS. COOPER
<br />11/13/2003 2 a 2 ASSISTAW- SIAT"E61$w R
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN_, fEWCES SYSTEIh . .
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND -"PORT -
<br />VITAL STATISTICS CERTIFICATE CERTIFICATE OF DEATH U
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />Dean Hershel Nearhood
<br />Male
<br />November 5, 2003
<br />4. CITY AND STATE OF BIRTH lff not ur U S.A.. name country)
<br />5a. AGE -Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6, DATE OF BIRTH /Month. Day. Year)
<br />Sb. MOS. DAYS
<br />Sc. HOURS' MINIS.
<br />PART
<br />II
<br />(Yrs.)
<br />IN THE PAST 3 MONTHS?
<br />Edgar, Nebraska
<br />82
<br />I
<br />November 22, 1920
<br />7. SOCIAL SECURTIY NUMBER
<br />rO
<br />505 -22 -9635
<br />HOSPITAL: ❑ Inpatient OTHER: Nursing Home
<br />- -- -
<br />❑ ER Outpatient ❑ Residence
<br />m
<br />n
<br />Beverly Health Care - Lakeview
<br />❑ DOA ❑ Other(Spectw
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />�
<br />C)
<br />o
<br />�
<br />�j
<br />ii
<br />9b. COUNTY
<br />Z
<br />C 1 '�
<br />9e. INSIDE CITY LIMITS
<br />r
<br />�•
<br />'`
<br />o�
<br />z A
<br />N
<br />CL
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican. German, etcl
<br />n
<br />©
<br />,
<br />x
<br />_
<br />r.t
<br />T7
<br />RI
<br />°
<br />15. EDUCATION (Specify only highest grade completed(
<br />of work'ng life, even ifretired)
<br />Diesel Mechanic
<br />a n
<br />D
<br />N't,
<br />1 FIRST MIDDLE MAIDEN SURNAME
<br />. J
<br />Grace Edith Dobson
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />o
<br />(Yes. no. or unk.) (If yes, give war and dates of services)
<br />3�
<br />No
<br />Imogene Nearhood
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.O. NO.. CITY OR TOWN. STATE. ZIP)
<br />308 E. Dodge St. Grand Island Nebraska 68801
<br />21 a. M ETHOD OF DISPOSITION
<br />21b. DATE
<br />CEMETERY OR CREMATORY NAME
<br />`
<br />UZZIP�01-o'd-0 #1071
<br />CD
<br />7, 2003 �ec.
<br />stlawn Mem. Pk. Cemetery
<br />a. FUNERAL HOME -NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home
<br />❑Cremation F1 Donation
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />2929 S. Locust St., Grand Island, Nebraska 68801
<br />(J
<br />f
<br />1PI
<br />e
<br />(,I Signature and Title) ►
<br />1
<br />I
<br />' 'T
<br />� -.�
<br />�
<br />S ire
<br />� F' 1
<br />f�
<br />to
<br />r-•F
<br />1:1 YES YES I}GI NO
<br />••��
<br />❑ YES ,KI NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or Prinr)
<br />Thomas Werner, M.D.,
<br />24 4 W. Faid y Ave., Grand Island, NE 68803
<br />32a, REGISTRAR
<br />321b . DATE FILED BY REGISTRAR iMo. Day Yr.)
<br />J
<br />t
<br />CD
<br />Q7
<br />CD
<br />L1-
<br />CO
<br />cn
<br />Lp
<br />CT
<br />Z O H
<br />CD
<br />P o tjj
<br />rn c+ P
<br />o 13
<br />y
<br />tV m
<br />0
<br />N• r�
<br />o ca
<br />C ''b
<br />0 (D
<br />�3 m
<br />P +
<br />C
<br />�• o
<br />m
<br />Ct
<br />P t'
<br />0
<br />U c+
<br />c
<br />H. O
<br />C
<br />cn t�
<br />H• �
<br />O
<br />� P
<br />r•
<br />C
<br />O
<br />C
<br />C: N
<br />H. to
<br />C, m
<br />O C
<br />L7 'G
<br />i-•
<br />Cn r>
<br />w r.
<br />p
<br />C+
<br />WHEN TM COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FA-E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEC IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />"-ANLEYS. COOPER
<br />11/13/2003 2 a 2 ASSISTAW- SIAT"E61$w R
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN_, fEWCES SYSTEIh . .
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND -"PORT -
<br />VITAL STATISTICS CERTIFICATE CERTIFICATE OF DEATH U
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />Dean Hershel Nearhood
<br />Male
<br />November 5, 2003
<br />4. CITY AND STATE OF BIRTH lff not ur U S.A.. name country)
<br />5a. AGE -Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6, DATE OF BIRTH /Month. Day. Year)
<br />Sb. MOS. DAYS
<br />Sc. HOURS' MINIS.
<br />PART
<br />II
<br />(Yrs.)
<br />IN THE PAST 3 MONTHS?
<br />Edgar, Nebraska
<br />82
<br />I
<br />November 22, 1920
<br />7. SOCIAL SECURTIY NUMBER
<br />Ba. PLACE OF DEATH
<br />505 -22 -9635
<br />HOSPITAL: ❑ Inpatient OTHER: Nursing Home
<br />- -- -
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY -Name (ff rof institution. give street and number)
<br />Beverly Health Care - Lakeview
<br />❑ DOA ❑ Other(Spectw
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes ® "d ❑
<br />Hall
<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 ]Grand
<br />Island
<br />308 E. Dodge St. 68801
<br />Yes ® No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican. German, etcl
<br />12. © MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE /if wife, give maiden name)
<br />etc]fSpecifyl White
<br />("e"'yl American
<br />NEVER DlvoaceD
<br />D F1 MARRI
<br />..Imogene Pracht
<br />14a. USUAL OCCUPATION (Give kind of work done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed(
<br />of work'ng life, even ifretired)
<br />Diesel Mechanic
<br />Government Ammunitions
<br />Elementary or Secondary (0 -12) College (1 -4 or 5 -1
<br />12
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />1 FIRST MIDDLE MAIDEN SURNAME
<br />John Nearhood
<br />Grace Edith Dobson
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />(Yes. no. or unk.) (If yes, give war and dates of services)
<br />TIME OF DEATH
<br />No
<br />Imogene Nearhood
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.O. NO.. CITY OR TOWN. STATE. ZIP)
<br />308 E. Dodge St. Grand Island Nebraska 68801
<br />21 a. M ETHOD OF DISPOSITION
<br />21b. DATE
<br />CEMETERY OR CREMATORY NAME
<br />`
<br />UZZIP�01-o'd-0 #1071
<br />❑X Burial ❑ Removal
<br />7, 2003 �ec.
<br />stlawn Mem. Pk. Cemetery
<br />a. FUNERAL HOME -NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home
<br />❑Cremation F1 Donation
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />2929 S. Locust St., Grand Island, Nebraska 68801
<br />GJ.
<br />PART "'""A C I.HUJt ItN I tH UNLT UNt GAUOt 1'tH LINt i'UH lab (o). ANU (C)) Interval between onset and death
<br />I la1 /rl /:l MYl�1.1 r !6 I ni'.� %.r�rs : - /II YI�'vG Tom. A.
<br />DUE TO, OR AS A CONSEOUEN F.
<br />Interval between onset and tleath
<br />flb� (..�f'fr-r9/r- S�•Lt��iVe
<br />pbir Y
<br />DUE TO, OR AS A CONSEQUENCE OF: r
<br />Inter al between onset and death
<br />I
<br />(cl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing
<br />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
<br />II
<br />PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONERh
<br />(Ages 10 -54) Yes No
<br />Yes No ]{
<br />Yes No X
<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 />Swcide Pending
<br />26e. INJURY AT WORK
<br />1 PLACE OF INJURY - At home, farm. street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />❑F-1
<br />Yes No ❑
<br />o we building. etc. /Specify)
<br />27a. DATE OF DEATH tMo.. Day. Yr)
<br />28a, DATE SIGNED (Mo., Day Yr)
<br />28b. TIME OF DEATH
<br />November 5, 2003
<br />- _
<br />d m
<br />Q
<br />M
<br />27b. DATE SIGNED (Mo.. Day Yr.)
<br />27a
<br />TIME OF DEATH
<br />�_ a
<br />28c. PRONOUNCED DEAD (Mo.. Day, Yr)
<br />28d. PRONOUNCED DEAD (Hour)
<br />E
<br />°
<br />2:35 A M
<br />�w5
<br />M
<br />27tl. To the best o my knowletlge. tle curved at theAime, d e and place and due to the
<br />° ° ° 28e. On the basis of examination and or investigation, in my opinion death occurred at
<br />~
<br />cause(sl stated.
<br />f
<br />° 5 the time, date and place and due to the cause(sl stated.
<br />,(Signature
<br />(,I Signature and Title) ►
<br />' "��� i is
<br />and Title/ ►
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION' BEE1N CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />KYES ❑ NO 1:1 UNKNOWN
<br />1:1 YES YES I}GI NO
<br />••��
<br />❑ YES ,KI NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or Prinr)
<br />Thomas Werner, M.D.,
<br />24 4 W. Faid y Ave., Grand Island, NE 68803
<br />32a, REGISTRAR
<br />321b . DATE FILED BY REGISTRAR iMo. Day Yr.)
<br />Nov 12 2003
<br />
|