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<br />
<br />STATE OF NEBRASKA
<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 REJ;€JJtDl>>f:F~ WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTJe.S'SECOONiWfflcH.IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. /1t~....)EftM.'...e.~.:,..::-;,:.;./ =._..':'_._~~.".-)~.'...\"
<br />
<br />DATE OF ISSUANCE "'7 "::'iJl-'!~o _ ----' ,,-- c,;
<br />NOV 2 8 2005 20051214 0 ASsb~NT~fi;;:Egg;'::l
<br />LINCOLN, NEBRASKA HEAL TH ANo...I'!Y'1AN,SEF}:VICES'
<br />
<br />:"-,.,'::',: ,.
<br />.....
<br />-..-
<br />.,
<br />...- -
<br />.-
<br />
<br />. _~_~ATE OF NEBRASKA - DEPAR~~~;rF~~ri~_~Q.E~Q~A~~VI~~~ F~N~N~~.A~_S~P:~Rb5-__1291~_
<br />
<br />1. DECEDENT'S.NAM~ (First, Middle, Lest, Sulflx) 2. SEX 3. DATE OF DEATH (Mo" Day, Yr)
<br />
<br />J
<br />
<br />
<br />Tnom::1
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />
<br />Jf---
<br />Sa. AG~-Last Birthday 5b, UND~R 1 Y~AR
<br />(Yrs,) MOS. DAYS
<br />
<br />,Male__,
<br />5c, UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />.O_V emb..euJ) _._2J1D3
<br />6. DATE OF BIRTH (Mo" Day, Yr,)
<br />
<br />Ci!_y, Iowa
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />63
<br />
<br />April 28, 1942
<br />
<br />8a. PLACE OF DEATH
<br />
<br />585-48-4034
<br />
<br />liOSEITAL
<br />
<br />o Inpatient
<br />
<br />Q.l]-iER: 0 Nursing Home/LTC 0 Hospice Facility
<br />
<br />8b. FACILITY-NAME (If not Instllution, give streel end number)
<br />
<br />o ER/Outpetlent
<br />
<br />Ii Decedent's Home
<br />
<br />509 Linden Avenue
<br />
<br />0[0\
<br />
<br />o Other (Specify)
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />
<br />9a, RESIDENCE-STATE .__=r'~:~N~-
<br />
<br />9d. STREET AND NUMBER
<br />509 Linden Avenue
<br />
<br />lOa, MARITAL STATUS AT TIME OF DEATH Merried 0 Never Married
<br />
<br />6d. COUNTY OF DEATH
<br />Hall
<br />
<br />J 9~ C;:O~T~WN I s 1 and ------
<br />- - ~-__ _ _ -J-9~APT~~ ;~~~
<br />
<br />lOb. NAM~ OF SPOUS~ (First, Middle, La.t, Sufllx) If wife, give maiden name,
<br />
<br />gg, INSID~ CITY LIMITS
<br />o YES ~ NO
<br />
<br />o Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Primrose Albee
<br />
<br />11. FATHER'S.NAME (First,
<br />Clair
<br />
<br />Middle,
<br />
<br />L..I, Suffix)
<br />Coll.wa y.. .
<br />
<br />12..MOTHER'S.NAME (Fir.t,
<br />Marie
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />Ruchala
<br />
<br />13, ~VER IN U,S, ARMED FORCES? Give dates ot service il yes. 14a.INFORMANT-NAME
<br />(Yes, no, Drunk.) no P r imr 0 s e Con wa y
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />15. M~THOD OF DISPOSITION
<br />r)Surlal 0 Donation
<br />
<br />o Cremation 0 Entombment
<br />
<br />16a. EMBALMER'SIGNAT~,
<br />
<br />__ (j 1JihY.<r. ./... af:J
<br />
<br />16d. CEME#RY, CREMATORY OR OTH~R LOCATION
<br />
<br />16b. LICENSE NO.
<br />1328
<br />
<br />CITY / TOWN
<br />
<br />16c. DATE (Mo., Day, Yr.)
<br />No v. 1 5 _,_ 2005
<br />STATE
<br />
<br />o Removal 0 Other (Specify)
<br />
<br />Gra!!..!L_~andC1:_~Y Cemetery
<br />17a. FUNERAL HOM~ NAME AND MAILING ADDRESS (Street, City orTown, St.te)
<br />
<br />Grand Island, Nebraska
<br />1 ?b. Zip Code
<br />
<br />
<br />
<br />18. PART I. Enler the chain of evenl.--dl....es, Injuries, or complicatlonsulhat directly caused the dealh, DO NOT enter lermlnal evenls such as cardiac arresl,
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl.e... or oondlllon re.ultlng
<br />In de.th)
<br />
<br />(a)
<br />
<br />Coronary Occlusion
<br />
<br />I
<br />I
<br />
<br />I onsetto death
<br />I
<br />I mi nutes
<br />
<br />___~_._.,"___.___ L
<br />I onset 10 death
<br />I
<br />I
<br />I
<br />I onset to deelh
<br />I
<br />
<br />respiratory arrest, or ventricular fibrillation wllhoul.showlng Ihe ellology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additionallin8S if necessary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />DUE TO, OR AS A CONSE;QUE;NCE OF:
<br />
<br />
<br />Sequentially list conditions, /1
<br />.ny, le.dln9 to the c.u.. listed
<br />on line..
<br />Entorth. UNDERLYING CAUSE
<br />(dl....e or Injury th.t inltlat.d
<br />tho ev.nts r.sultlng In death)
<br />LAST
<br />
<br />(b)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(0)
<br />DU~ TO, OR AS A CONSEQUENCE OF:
<br />
<br />. ~___.L_.__._
<br />I onset to death
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Condlllon. contributing to the death but not resulting in the underlying cause given in PART I.
<br />
<br />19 WAS MEDICAL EXAMIN~R
<br />OR CORONER CONTACTED?
<br />:tJ YES 0 NO
<br />
<br />
<br />20. IF FEMALE:
<br />o Nol pregnanl within pasl year
<br />o Pregnant allirne of death
<br />o Nol pregnant, bul pregnant withm 42 days 01 death
<br />o Not pregnant, but pregnant 43 days to 1 year before death
<br />o Unknown if pregnant within the past year
<br />
<br />21 a. MANNER OF DEATH
<br />~ Natural 0 Homicide
<br />
<br />21 b.IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />U Drlver/Operalor
<br />
<br />U Accident 0 Pending Inve.llg.llon
<br />U Suicide U Could not be determined
<br />
<br />o Passenger
<br />o Pedestrian
<br />U Other (Speclly)
<br />
<br />o YE;S
<br />
<br />Xj(NO
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES Q!l NO
<br />
<br />o Y~S U NO
<br />
<br />
<br />22a. DATE OF. INJURY_ (MQ.. Day, Yr,)
<br />
<br />22b. UM~ Of_INJURY ~--AOE 0~-tNJURY.Athom., !.rm'-smlet, tactory, OIfice building. construction stte, etc. (Speclly)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CfTYlfOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23,. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />m
<br />
<br />Z,.
<br /><<uJ
<br />~-%
<br />.c~a:
<br />""'0
<br />~H:
<br />a. a.. C( ::;
<br />~n~
<br />"Uj %
<br />,8%::>
<br />00
<br />~a:O
<br />815
<br />
<br />24, DATE SIGNED (Mo., D.y, Yr.)
<br />
<br />\:: \5::'05______
<br />
<br />240. PRONOUNC~D DEAD (Mo" Day, Yr,)
<br />November 10, 2005
<br />
<br />24b. TIME OF DEATH
<br />0100 m
<br />
<br />23b, DATE SIGN~D (Mo" Day, Yr,)
<br />
<br />23c. TIME OF DEATH
<br />
<br />24d, TIM~ PRONOUNCED DEAD
<br />1400 m
<br />
<br />23d. To the bast 01 my knowledge, death occurred a1 the time, date and place
<br />and due to Iha cause(s) slaled, (Signature and Title) l'
<br />
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TOTH~ D~ATH?
<br />
<br />___.)0 YES ... 0 NO OPROBABLY 0 UNKNOWN 0 YES I2t NO
<br />27. NAME,lmEANo-ADDR'ESSOF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYl (Type or PrintJ.
<br />David Waskowiak, Inv. Hall County Sheriff's Offlce. 131
<br />
<br />Not Applicable II 26a is NO U YES 12} NO
<br />
<br />S. Locust, Grand Island, NE
<br />
<br />8801
<br />
<br />I
<br />
<br />
<br />26b. DATE FILED BY R~GISTRAR (Mo" Day. Yr.)
<br />
<br />28a, R~GISTRAR'S SIGNATURE
<br />
<br />NOV 2 2 2005
<br />
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