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<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 REC08D ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS S~9l!QN,_ _WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. -~~i~~~-'-
<br />
<br />DATE OF ISSUANCE )VV-'ll~.i~~~.
<br />
<br />QJ.:'C 0 82011' ASSIs1Am~~.~'~~I!I7"R~'ii
<br />. L7NCOLN, NEBRASKA HEALTiY'N.tHf/MA~JlJc(g,
<br />200600093 " ..... -; _.~:"= _~". _ c .
<br />
<br />.. ~._':-;'::::-=~ =-=:~~:::t~:~'"",
<br />
<br />~~~.::~~~i':"~~g:~~~',:,. .~~,:;~.:
<br />STATEOFNE. BRASKA-OEPA.RTMENTOFH. E. ALTHANOHUMA... N SERVICESFINA~.._..lN.._..lli1,_~.~._.~~ 5 13.3.....00
<br />. __9ERTIF:ICATE OF DI;.ATH ',- C_"---".- _J,J
<br />
<br />(First, Mlddla, Last, Sullix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Harold Edwin Bessey Male November 23, 2005
<br />
<br />"4 CITY AND STAT~ ~R TERRITORY, OR-FOREIGN COUNTAy-oiFIRTH Sa AGE.Lasl Blrthda; 5b - UNDER '. Y~AR 5c. UNDER 1 DAY 5. DATE OF BIRTH (Mo. D~;~
<br />(Yrs.) MOS DAYS HOURS 'j -M.INE:.
<br />Omaha, Nebraska 83 February 16 1922
<br />
<br />
<br />507-14-7332
<br />
<br />8a. PLACE OF DEATH
<br />!iO.S..elIAl.:
<br />
<br />dClnpati.nt
<br />
<br />QlliE8; 0 Nursing Home/LTC 0 Hospice Feclllty
<br />
<br />8b. FACILlTY.NAME (If not Institution, give aue.t and number)
<br />
<br />o ER/Oulpatient
<br />
<br />o Docedent's HOille
<br />
<br />St. Francis Medical Center
<br />
<br />~'.J
<br />
<br />8e. CITY OR TOWN OF DEATH (Include Zip Cod.)
<br />Grand Island, 68803
<br />9.. RESIDENCE.STATE --1gb. COUNTY
<br />Nebra.~~___LH_all
<br />9d. STREET AND NUMBER
<br />4243 Pennsylvania Ave.
<br />10a MARITAL iiTATUS ATTIME OF DEATH ~ Married U Never Married
<br />
<br />o ro\ 1:1 Other (Sp.cily)
<br />
<br />~UNTY OF DEATH
<br />Hall
<br />
<br />9c. CITY OR TOWN
<br />Grand Island
<br />
<br />==to APT. NO 91.~~~~;
<br />
<br />lOb. NAME OF SPOUSE (First, Middle, La.1. Suffix) If wife, give maid.n name.
<br />
<br />"~~-ECITYLlMITS
<br />_I cXYES I..l NO
<br />". .'.,'-~
<br />
<br />o Marriad, but.ep.r.ted 0 Widow.d I..l Divorced 0 Unknown
<br />
<br />11. FATHeR'S-NAME (Flrsl, Middle, Lasl,
<br />Charles E. Bessey
<br />13. EVER IN U.S. ARMED FORCES? Give datas 01 ,erviee If yes. 14a.INFORMANT.NAME
<br />(Yes, no,o:u~k)Y es 11":'3-::,194...2 ~ 1946__.M. aryaIl!l:~,
<br />15. METHOD'OF DISPOSITION 16.. EMB -SIGN ~E
<br />XJG!url.1 0 Don.llon
<br />o Cremation 1:1 Emombment 16d. CEMETERY, CREMATORY R OTHER LOCATION
<br />
<br />Suffix)
<br />
<br />e.
<br />
<br />MaryanIl~_Marshall
<br />MOTHER'S.NAME (Flr.t,
<br />Eleanor
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />McIvor
<br />
<br />Bessey
<br />16b. liCENSE NO.
<br />/2 (ltJ
<br />CITY /TOWN
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />16c. DATE (Mo.. Day, Yr.)
<br />. _~ovember 26, 2005
<br />STATE
<br />
<br />I..l R.moval 0 Other (Specify)
<br />
<br />Grand Island City Cemetery
<br />L.. __
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreet, City or Town, Stal.)
<br />Apfel Funeral Horne
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />
<br />PART I. Enler Ihe ch.ln of .v.nls..dis....., Injuri.., or complle.,lon'nlhat dir.clly cau..d the death. DO NOT emer fermlnalev.nl. such a. c.rdl.c .rrest,
<br />rasplratcry arrest, or venlrJcular fibrillation withoUi ,oI:howlng the etiology. DO NOT ABBREVIATE. Enter only one Cause on a line. Add addlllonallines If necessary.
<br />
<br />IMMeDiATE CAUSE (Final
<br />dt..... or condition ...ulllng
<br />Ind.ath)
<br />
<br />(a)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />5i-,o k c
<br />
<br />onsel to death
<br />
<br />S.quenll.lly lI.t condlllons, II (b) / f
<br />.ny, leodlng 10 tha caus.lI.ted DUE TO, OR--- A
<br />on line II,
<br />Enterthe UNDERLYING CAUSE
<br />(dlseas. or Injury th.t tnlll.t.d (c)
<br />the event. ...ulllng in de.th)
<br />lAST
<br />
<br />"J<..:X~.-2.-'-"'~
<br />NSEQUENCE OF:
<br />
<br />"
<br />
<br />(.e,..~.~~~~.J)-a..~..
<br />
<br />-l /,\!-('-,,-,l!'7
<br />
<br />I cns.1 to de'lh
<br />I
<br />
<br />(;p.t.~~ 30 C . --<'""'~__
<br />
<br />I on.et 10 de.t
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:.
<br />
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />on..1 to de.th
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS'Condlllons contributing to Ihe deoth but nol resulting In the underlying cau.e given In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />o YES )a NO
<br />
<br />20. IF FEMALE: 21a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Not pregnant within pa.t y.ar )il(Natur.1 0 Homicide 0 Driver/Operator
<br />
<br />I..l Pragnanl at lime 01 deolh 0 AcoldantO Pending Inve.tlgation 0 pas.enger
<br />
<br />Cl Not pregnsnt, bul pregnanl within 42 day. of death I..l Sulcid. 0 Could not be d.t.rmined 0 P.deslrlan 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Not pr.gnant, but pr.gnanl43 days to 1 yaar b.'ore deoth I..l Other (Specily) COMPLETE CAUSE OF DEATH?
<br />o Unknown II pregnanl within the p.st year 0 YES U NO
<br />
<br />22a. DATe OF INJURY (Mo., Day, Yr.) .J2';b. TIME OF INJUR; _ 22c. PLACE OF INJURV.At home, farm, str.et, tactory, otllee building, construction .Ite, ale. (Sp.cily)
<br />
<br />
<br />22d.INJURV AT WORK? 22... DESCRtBJ; HOW INJVIlY OCCURRED"
<br />
<br />LJ YES
<br />
<br />)i(NO
<br />
<br />o YeS Cl NO
<br />
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />SlJITE
<br />
<br />ZIP CODE
<br />
<br />24a. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />24b. TIMe OF DEATH
<br />
<br />m
<br />
<br />,.,~~
<br />"'~~
<br />h~
<br />c.D. iJ:( ~
<br />E(/)(:z
<br />8ffi!:i:O
<br />"Z::>
<br />"'00
<br />~a:U
<br />o~
<br />UO
<br />
<br />m
<br />
<br />240. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the ba.i. ot .xaminallon .nd/or Inv.sligalion, in my opinion death occurred al
<br />Ihe lime, date and place and due to the cau.e(.) .t.ted. (Signa lure and Tille) T
<br />
<br />25. DID TOBACCO USE CONT IBUTETO HE DEAr. 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />
<br />U YES 0 NO . br~ROB I lY U UNKNOWN 0 YES .... .)orNO . NotAppllcabl. if 26.ls NO 0 YES U NO
<br />----v:-NAM~ TITLE"AND AD~i OF CERTIFIER (PHY~qAJ:j, CORONEFfSPHYSICIAN OR COUNTY ATTOj1NEY) (Typ. o~ prinl) '-"..
<br />Dr. uordon J..Hrnicek /z~ North Custer Grand Island. Nebraska 68803
<br />
<br />28.. REGISTRAR'S SIGNATURE
<br />
<br />
<br />J.
<br />
<br />
<br />26b. DATE FILED BY REGISTRAR (Mo" Day. Yr.)
<br />
<br />DEe='2 2005
<br />
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