|
<br />y
<br />
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS 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 RECOlJDON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA1J$'tC$.~~_WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . _~':'f,o:'o='-" -o:~J--:---=-- -o~:__
<br />
<br />~~~~~~ ~~~~
<br />LlNC~~N~8;}~5 200511282' ~~~:~~
<br />
<br />
<br />STATE OF NEI3RASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES ~N~:;';~-W...~.JPqR;T... '.'r"l'5...-- 08950
<br />CERTIFICATE OF DEATH c_.,- '. 0 - -~o.).;;l,
<br />
<br />50. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />'-,'l,DATE OF DEATH (MD., Day, Yr.)
<br />
<br />~.!:!~~___!'Q.L _ ~gg_?
<br />6. DATE OF BIRTH (Mo" Day, Yr.)
<br />November 17, 1934
<br />
<br />DECEDENT'S-NAME (First, Middle, Last, Suffix)
<br />_B_1ll y- _u_ HQR.~_.t..9__ -_-1~1glJtY --. - --- -
<br />4 CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a AGE.Last Birthday 5b UNDER 1 YEAR
<br />Logan, Kansas (Yrs) 70 MOS DAYS
<br />
<br />-- - ---- ~ - -...-.-.-.-
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />
<br />2.SEX
<br />Male
<br />
<br />J:lQ.SEllAl.:
<br />
<br />o Inpallant
<br />
<br />~: M Nursing Home/l TC 0 Hospice .Facility
<br />
<br />FACILITY-NAME (If not Institution, giva straat and numbar)
<br />
<br />o ERIOutpatiant
<br />
<br />o Decedent's HOIl"3
<br />
<br />Haven Home
<br />
<br />o ro\ 0 Othar (Spacify)
<br />8c. CITY OR TOWN OF DoATH (Includa Zip Code) 8d. COUNTY OF DEATH
<br />
<br />Kenesaw, 68956
<br />geo RESIDENCE.STATE
<br />
<br />Adams
<br />
<br />9b. COUNTY
<br />Adams
<br />
<br />90. CITY OR TOWN
<br />Kenesaw
<br />
<br />100 W Elm Ave.
<br />
<br />
<br />91. ZIP CODo
<br />68956
<br />
<br />I~;~;~CIT~~~~~
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH - U Married U Navar Marriad lOb. NAME OF SPOUSE (Flral, Mlddla, Last, Sulflx) II wlfa, give maidan name.
<br />
<br />LJ Merried, but separated ~ Widowed [J Divorced [J Unknown
<br />
<br />Pearl
<br />
<br />Kurth
<br />
<br />11. FATHER'S-NAME (First,
<br />Willard __
<br />
<br />Middla, Last,
<br />Leiqhty
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S-NAME (First,
<br />violet
<br />
<br />Middle,
<br />Griffin
<br />
<br />Malden Surname)
<br />
<br />13. ~VoR IN U.S. ARMED FORC~S? Give dates of sarvica if yas. Ha.iNFORMANT-NAME
<br />(Yes, no, Or unk.) Yes, 1954-1962 Cheryl Sandoe
<br />
<br />15':::~a~OFDI~~:~::~~ :6':EM:A~~k)fT~~_ ' 0d/~_
<br />
<br />o Cremation 0 Enlombment 16c1~~~, CREMATORY OR DTHER LOCATION
<br />
<br />l6b. LICENSE NO.
<br />1163
<br />
<br />14b. RELATIONSHIP TO DoCODENT
<br />Daughter
<br />
<br />16c DATE (MD., DaY'!':31
<br />August ~ 2005
<br />
<br />CITY I TOWN
<br />
<br />STATE
<br />
<br />U Ramoval 0 Othar (Spacity)
<br />
<br />Sunset Memorial Gardens
<br />
<br />Hastings
<br />
<br />Nebraska
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Streel, City or Town, Stale)
<br />IEWitt F'1..lrRal H:ne am Craratim ServiCE, 1247 N. BJrlirlJtm !we., ~, NE
<br />
<br />
<br />
<br />PART I. enter the ~t:!"~,t.~~.r1!~,--dis8a:;;,,,s. lnjuriM. or cOITlf-'licalions--lhal directlv caused the rlp.~lh. DO NOT enl~( Ip.rmlnal p.venls !;uch as cardiac arrest,
<br />respiratory a"aSl, or ventrlcuiar flbrlliation without showing tha atioiogy. DO. NOT ABBREVIATE. ~nter only one cause on alina. Add additional lines if necessery.
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl..... .,condltion re.ultlng
<br />In death)
<br />
<br />::~"~::: - A # fd:aL/
<br />-- ---- I-~~ -
<br />DUE TO, OR AS A CONSEOUENCE ......,---
<br />
<br />(b) 0_ a/hu; ~~
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />Sequentlatiy lI.t condlllon., II
<br />!lny, leading to the cause listed
<br />on IIna a.
<br />Ente'theUND~RLYING CAUSE
<br />(disease or Injury that Initiated
<br />the events resulting in death)
<br />LASr
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />~ ~onsaltOdaath
<br />1- "---
<br />
<br />I onset to death
<br />I
<br />I
<br />
<br />onset 10 death
<br />
<br />(d)
<br />
<br />o Pregnant at time of death
<br />o Not pragnant, but pregnant wilhin 42 days of death
<br />o Not pregnant, but pregnant 43 dey. to 1 year before death
<br />o Unknown if pregnant within tha pa'l year
<br />22a. DATE OF INJURY (Mo., Day, Yr.) --r22b TIME OF INJUR:
<br />
<br />o AccldentO Pending Invastigation
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />o passangar
<br />
<br />o Padastrlan
<br />
<br />o Other (Specify)
<br />
<br />19. WAS MEDICAL ~XAMINER
<br />OR CORONER CONTACTED?
<br />o YES XI NO
<br />21 c. WAS AN AUTOPSY PERFORMED?
<br />
<br />PART Ii. OTHER SIGNIFICANT CONDITIONS-Conditions conlrlbUllng 10 the dealh but not ..suiting In tha undarlying causa given In PART I.
<br />
<br />20. IF FEMAL~:
<br />U Not pragnant within past yaar
<br />
<br />21a. MANNER OF DEATH
<br />~ Natural 0 Homicide
<br />
<br />DYES
<br />
<br />1tI NO
<br />
<br />U Suicide U Could not ba dalarmined
<br />
<br />2ld. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />U YES
<br />
<br />ONO
<br />
<br />22c. PLACE OF INJURY-At home, farm, straat, factory, ofliea building, construction .ite, elc. (Spacily)
<br />
<br />22d.INJURY AT WORK?
<br />
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />U YES U NO
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. ND.
<br />
<br />CrTYrrOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Au Hst 10, 2005
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo.. Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of ax ami nation and/or investigation, In my opinion daaih occurred at
<br />lhe lime, date and place and due to the CAuse(s) slated. (Signature and Tille) T
<br />
<br />U YES NO 0 PROBABLY ~ U.~KNOWN U YES tho .___....
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type Dr Print)
<br />James W. Miller, M.D. 1021 W 14th St., PO Box 968
<br />
<br />28a. REOISTRAR'S SIGNATURE
<br />
<br />2Sb. WASCONS~NT GRANTED?
<br />Not Ap?~1.9abl~ If 26a Is NO [J YES [J NO
<br />
<br />Hastings, NE
<br />
<br />68901
<br />
<br />
<br />28b. DAT~ FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />
<br />AUG 15 2005
<br />
|