|
<br />~\
<br />{
<br />\
<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 RECQfl!1J~Mfl~EWITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSTlq~~l?,r1fJ!li.~ IS
<br />
<br />:::~::~~:::::~TORY FOR VITAL RECORDS. ~!~7f,f~~-;{4:.
<br />
<br />)V""'fr~~T~~Y~. f;OO~:~
<br />NOV 3 0 2005 ASSl!3TA/'iT srATEJlEGI$T"lfR"
<br />LINCOLN, NEBRASKA 2 0 0 5 12 0 7 3 HEALt-~ ANo,.!1_~~A~~~ERl(jCE!i-=
<br />
<br />--,.-.,:.~...~
<br />
<br />."',~-
<br />.. - - -
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINKNCE ANfffiuppeJ;lf
<br />CERTIFICATE OF DEATH
<br />
<br />~",
<br />"
<br />
<br />
<br />o 5--.03-4-7--4
<br />3, DATE OF DEATH (Mo., Day, Yr,)
<br />March 21, 2005
<br />
<br />DECEDENT'S-NAME (First,
<br />Betty
<br />
<br />Middle,
<br />Darlene
<br />
<br />Last,
<br />". K~nny
<br />
<br />Suffix)
<br />
<br />2,SEX
<br />Female
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />
<br />Sa, AGE-Lest Birthday 5b, UNDER 1 YEAR
<br />
<br />(Yrs,) 79 MOS DAYS
<br />
<br />5c, UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6, DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />October 30, 1925
<br />
<br />7. SOCIAl SECURITY NUMBER
<br />506-28-3426
<br />
<br />6a, PLACE OF DEATH
<br />f;iQSfllt-J,' [J Inpatlenl
<br />
<br />QII;1Efj: ~ Nursing HomelUC 0 Hospice Facility
<br />
<br />FACILITY-NAME (II not Institution, give street and number)
<br />
<br />o ER/Outpatient
<br />
<br />o Decedent's Home
<br />
<br />Beverly Realthcare Lakeview
<br />
<br />OM
<br />
<br />U Other (Specify)
<br />
<br />8c, CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />Grand Island
<br />
<br />8d, COUNTY OF DEATH
<br />
<br />68801
<br />
<br />Hall
<br />
<br />1~0;;:~_2sland ""','
<br />1ge, APT, NO 91, ZIP COD,E
<br />68801
<br />....---.--.-.--..
<br />.....---..
<br />lOb. NAME OF SPOUSE (First, Middle, Last, Suffix) II wife, give maiden neme,
<br />
<br />--~SIDE CITY LIMITS
<br />iXi YES [J NO
<br />
<br />9a, RESIDENCE-STATE
<br />Nebraska
<br />9d, STREET AND NUMBER
<br />2114 Pioneer Blvd.
<br />10a, MARITAl STATUS ATTIME OF DEATH 0 Married 0 Never Married
<br />
<br />9b, COUNTY
<br />
<br />Hall
<br />
<br />o Married, bute.parated \l{Widowed 0 Divorced 0 Unknown
<br />
<br />Martin Kenny, Jr.
<br />
<br />1 UATHER'S-NAME Z:~'l Middle, Ha~~'is~~;;;;;--C~_ER'S-~AME
<br />
<br />
<br />13, EVER IN U,S, ARMED FORCES? Give dates 01 service if yes, 14a.INFORMANT-NAME
<br />
<br />(First,
<br />Tina
<br />
<br />Middle, Maiden Surname)
<br />Schlieker
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />
<br />(Yes, ho, or unk.) No
<br />15. METHOD OF DISPOSITION
<br />alBurial U Donallon
<br />
<br />
<br />Son
<br />16c, DATE (Mo" Day, Yr, )
<br />
<br />March l?,. 200,5_
<br />STATE
<br />
<br />Kenny
<br />
<br />16aEMB%::;;U - ----=t::.~:~N~;5~r
<br />
<br />16d, CEMETERY, CR~ATORY-;;R OTHER lOCATION CITY I TOWN
<br />
<br />o Cremalion 0 Entombment
<br />
<br />o Removal 0 Other (Speolly)
<br />
<br />Wood River Cemetery
<br />
<br />Wood River,
<br />
<br />Nebraska
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Slreet, City orTown, Slate)
<br />
<br />
<br />'P.O. Box 126, Wood River, NE
<br />
<br />
<br />PART l. E.nter lhe chain 01 Avents--dlseases, Injuries, or compllcations..that dlreotly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or venlrlouler fibrillation without showing the etiology, DO NOT ABBREVIATE, Enler only one cause on a line, Add oddlllonalllnas If necessery,
<br />
<br />APPROXIMATE INTERVAl
<br />
<br />IMM~DJJ\
<br />
<br />AUSE,
<br />
<br />ons8110 death
<br />
<br />6~-tf2iP.'5/'J
<br />
<br />onsetto death '
<br />
<br />IMMEDIATE CAUSE (Fln.1 (e) 1~1;t,vV.1!:t-:a..
<br />di....eorcondltlonresultlng DUE TO, OR AS A CONSEQUENCE OF:
<br />In death) " /:
<br />
<br />Sequenllally lI.teondltlons, If __(b). ._.G.,vt-I YA/L rV'I--4_~(..+'Z- ~'Cc-..a.......r ( $?trk )_
<br />any, leedlng tothe cause IIstsd DUE TO, OR AS A CONSEQUENCE OF: -
<br />on line 8.
<br />Enter the UNDERlYING CAUSE
<br />(disease or Injury thet Initialed (c)
<br />the evento re.ultlng In death)
<br />LA'1T
<br />
<br />Lf,IAA"tL'/k-
<br />
<br />onset to death
<br />
<br />..-.1.
<br />I ons.tto death
<br />I
<br />I
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying ceuse given In PART I.
<br />
<br />19, WAS MEDICAl EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />[J YE_~____~
<br />
<br />21c, WAS AN AUTOPSY PEfORMED?
<br />
<br />o YES ~
<br />
<br />.'..--.--..,..
<br />20.IVEMALE:
<br />~ot pregnant within past year
<br />o Pregnant al time 01 deeth
<br />o Nol pregnant, but pregnant within 42 days of death
<br />o Not pregnant, bul pregn.nl43 days to 1 year betore death
<br />LJ Unknown if pregnant withIn Ihe pasl year
<br />
<br />21a, MA~ER OF DEATH
<br />~Natural 0 Homicide
<br />
<br />21b.IF TRANSPORTATION INJURY
<br />tJ Driver/Operator
<br />
<br />o Passenger
<br />
<br />[J Pedestrian
<br />
<br />o Other (Specify)
<br />
<br />L.l AccldentO Pending Investigation
<br />o Suicide I:.l Could nol be delermined
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />[J YES 0 NO
<br />
<br />PLACE OF INJURY-At home, larm, streel, factory, office building, construction site, etc. (Specify)
<br />
<br />ClTYffOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />~
<br />
<br />23a, DATE OF DEATH (Mo" Day, Yr,)
<br />
<br />Mcl];.Qh2t/2005~_
<br />23b, DATE SIGNED (Mo" Day, Yr,)
<br />r ..1'"( h 22 I 2005
<br />
<br />m
<br />
<br />24C. PRONOUNCED DEAD (Mo" Day, Yr,) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />24a, DATE SIGNED (Mo" Day, Yr,)
<br />
<br />24b, TIME OF DEATH
<br />
<br />z>
<br />~~~
<br />_0:
<br />H~
<br />Q,.c:L 'C ~
<br />e"'>z
<br />8ffi!z0
<br /><>z::l
<br />.000
<br />~a:U
<br />8 ~
<br />
<br />m
<br />
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the lime, date end piece end due to the ceuse(s) slated. (Sign.tura and Tille) T
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />____\_ ... _~,,__..9_NO 0 PROBABLY w/u'~KNOWN _ [J YES_,. ...... ~
<br />27, AME, TITlE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Prlnl)
<br />John Wagoner M.D. 800 N. Al ha Ave., Grand Island NE.
<br />
<br />4u
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />Nol Applicable if 26a is NO 0 YES 0 NO
<br />
<br />68803
<br />
<br />28e. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b, DATE FILED BY REGISTRAR (Mo" Day, Yr,)
<br />
<br />MAR 2 8 2005
<br />
|