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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANDHUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSTICS$E~T-I.Q/'!,_ WHICH IS
<br />
<br />:::::::::::::~TORY FOR VITAL RECORDS. ;1/ ~ii.~...~..'-..=.~i~~.-:,-..~.-~. -.....~-~~~..~.t.'o
<br />IAN 0 6 2006 }J7~S.C-CMPifR
<br />AsfBlstAN~~fiffl.AR
<br />HE.4fT,,!~~ND HUAMN$JiRy~eEs
<br />
<br />200601095
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />",-.
<br />
<br />
<br />.':... .. _ __u,~_'';;:':.-: ,~~" ..
<br />
<br />__.._____'.._._..~TATE OF NEBRASKA - DEPAR~~~;tF~~f;~N~~~~iN~-[~~~~~S F'N~~~_~~~~~fJ5~j~lA,-6__5,Q'
<br />
<br />1. DECEDENT'S.NAME (First, Middle, Last, Suffix) 2, SEX ..- --'. :UtE'OF-DEATH (Mo" Day, Yr.)
<br />
<br />J::ecati:ff 2fh._1QlL,,__..
<br />
<br />~-_1\l..fra:L__ ___
<br />
<br />
<br />~EL
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa, AGE-Last Birthday 5b, UNDER 1 YEAR
<br />(Yrs,) MOS. DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo" Day, Yr.)
<br />
<br />Humphrey, Nebraska
<br />
<br />88
<br />
<br />JUly Xl, 1917
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />507-21T1Q?}_ .,
<br />
<br />8a, PLACE OF DEATH
<br />
<br />~:
<br />
<br />LJ Inpallen'
<br />
<br />QlliEB:
<br />
<br />I2ll Nursing Home/lTC 0 Ho.plce FacllI,y
<br />
<br />8b, FACILITY-NAME (II nol Institulion, giva slraat and numbar)
<br />Veterans Affairs M:rlical CEnter
<br />2201 Nrth Bt1::a:Mill
<br />
<br />LJ ERIO,'ipallent
<br />
<br />LJ Decedenl's Home
<br />
<br />O[l)\
<br />
<br />IJ Other (Spaclty)
<br />
<br />8e, CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />8d, COUNTY OF DEATH
<br />Hill
<br />
<br />9a. RESIDENCE.STATE
<br />
<br />_____ _J 9b,CO~;;Ll
<br />
<br />[2;;r~~:____________._.. ,_____________
<br />
<br />9a. APT. NO 91. ZIP CODE
<br />6?ffi1
<br />
<br />
<br />9g. INSIDE CITY LIMITS
<br />}!J YES 0 NO
<br />
<br />9d, STREET AND NUMBER
<br />
<br />172A E. ~A~~_
<br />lOa, MARITAL STATUS ATTIME OF DEATH i2j:~~;;ied 0 Naver Married
<br />
<br />lOb, NAME OF SPOUSE (FirS!, Middle, Laot, Sufllx) If wife, glva mald.n name,
<br />
<br />o Marrl.d, but ..paral.d 0 Wldow.d ODivorc.d 0 Unknown
<br />
<br />Mary Ternus
<br />
<br />II, FATHER'S-NAME (FirS!,
<br />
<br />Mlddl.,
<br />
<br />Last,
<br />
<br />Suftix)
<br />
<br />12. MOTHER'S.NAME (First, Mlddla,
<br />Grace (NMI) Hastrieter
<br />
<br />Maiden Surname)
<br />
<br />_~1f,ar~__. (~....!l_ LabE:l_nz
<br />13. EVER IN u,s, ARMED FORCES? Glv. dal.. of servlc.lf y.s, 14a, INFORMANT-NAME
<br />(Y.s, no, Or _u~~0~_ ~1/3.~~9~1/25/~__ Mary Ternus
<br />
<br />15. ::::~ OF D1~::~::i:~ 16:~J;2;;~OJJi/:{_____ ___
<br />o Cramation 0 Enlombmant 16d, CEMETERY, CREMATORY OR OTHER LOCATION
<br />o R.moval 0 Other (Spacify)
<br />
<br />CITY /TOWN
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />16c, DATE (Mo" Day, Yr'2006
<br />
<br />Janu~;:y_~__g, e e_::;__
<br />STATE
<br />
<br />16b, LICENSE NO.
<br />
<br />t /.t3
<br />
<br />Ft. McPherson National Cemetery, Maxwell, Nebraska
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Streel, City or Town, St.te)
<br />
<br />17b. Zip Coda
<br />
<br />St., Grand Island, NE
<br />
<br />68803
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />raspiratory arr.sl, or vanlrieular tibrillation without showing tha etiology, DO NOT ABBREVIATE, Enter only on. caus. on a line, Add additional Iln.s It nec..sary,
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onset to death
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl~ase or condition re$ultlng
<br />In death)
<br />
<br />Sequ.ntlaltyll.tcondltlon.,U (b) ~ive MJsailar
<br />any, 'o.dlng to the cau"II.tad DUE TO, OR AS-A' CONSEQUENCE OF:
<br />on line a.
<br />EnlortM UNDERLYING CAUSE
<br />(dl..... or Inlury lh.t Inltlal.d (c)
<br />Iho ..onl....ullln9 In doath) DUE TO, OR AS A CONSEQUENCE OF:
<br />lAST
<br />
<br />(a) Aspiratim!hmrnia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />2 days
<br />
<br />~
<br />
<br />I on..t to dealh
<br />I
<br />
<br />:rrmy years
<br />
<br />I ons.t 10 death
<br />I
<br />I
<br />I
<br />
<br />Ohsetlo death
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the daa'h bu' no' resulting In Ihe und.rlylng causa given In PART I,
<br />
<br />19, WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />o YES ~ NO
<br />
<br />_____D:ial::etes M:illitus
<br />20. IF FEMALE:
<br />
<br />o Not pregnant within past year
<br />o Pregnanl el lime of d.ath
<br />o Not pregnant. but pregnant within 42 days 01 death
<br />[J Not pregnan(, but pregnanl43 days 10 1 year before dealh
<br />o Unknown if pregnant within the past year
<br />
<br />21., MANNER OF DEATH
<br />~ Natural 0 Homicide
<br />
<br />21b.IFTRANSPORTATION INJURY 21c, WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />o Accid.ntO Panding Invastlgatlon
<br />
<br />o pass.ng.r
<br />o Pedestrian
<br />
<br />DYES
<br />
<br />10 NO
<br />
<br />o Suicide 0 Could not be determined
<br />
<br />o Olh.r (Sp.clfy)
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABlE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES 0 NO
<br />
<br />22a, DATE OF INJURY (Mo" Day, Yr,)
<br />
<br />
<br />22c, PLACE OF INJURY-At horn., farm, street, lactory, olflce building, construcllon .ite, .Ic. (Sp.clly)
<br />
<br />
<br />22d, INJURY AT WORK?
<br />
<br />22e. DESCRIBE HOW fNJURY OCCURRED
<br />
<br />LJ YES 0 NO
<br />
<br />221. lOCATION OF INJURY - STREET & NUMBER, APT. NO,
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />'"
<br />Z:!!
<br />]~
<br />!~~
<br />E"-",
<br />,; "'0
<br />U c
<br />H
<br />~~
<br /><l
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr,)
<br />
<br />_~.....~L_?f1J5
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Ieca1i:ff 28 '2JJJ5
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr,)
<br />
<br />24b, TIME OF DEATH
<br />
<br />23c. TIME OF DEATH
<br />5:9) am
<br />
<br />z~~
<br />_0:
<br />]!~~
<br />-aKic(~
<br />E"~ ~ Z
<br />DO: 0
<br />UUJ
<br />~z::::>
<br />.coo
<br />~a:t)
<br />81;
<br />
<br />m
<br />
<br />24c, PRONOUNCED DEAD (Mo" Day, Yr,) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To the bast 01 my knowledge, death occurr.d at the 11m., dale and place
<br />and due to the causB(s) slal8d~ignature and Title) T
<br />\:-u..:.J'1'-.()..'\ - -\ \}
<br />-- ! .
<br />
<br />248. On the basis of examination and/or investigation, in my opinion death occurred at
<br />Ihe IIrne, date and place end due to the cau..(s) stal.d, (Slgnalure and Tille) T
<br />
<br />25, DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />26a, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />l
<br />
<br />
<br />DYES LJ NO 0 PROBABlY :lS;l UNKNOWN 0 YES (X NO No' Appllcabl.lf 26a Is NO 0 YES i!3 NO
<br />. -27, NAME;TiTLEAND-ADDRESS OF CERTIFIER (P YSICIAN, CORONER'S PHYSICIAN OR COUNTY ATIORNEy)p'ype or Print) - " I;. Il.N-[( r.J'H.Ji')
<br />\LN'^, \c..~"-"'k'1\.l., Vr\f"\(.. c,U\~f) Q.)c.Jo.-.....\0 :J.:>--O\'~, ~()W~t..L. ~ .....~~Ij'},i.&...:,1- I
<br />
<br />28a, REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b, DATE FILED BY REGISTRAR (Mo" Day, Yr,)
<br />
<br />JAN
<br />
<br />4,2006
<br />
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