|
<br />6
<br />
<br />J
<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. RE11080 cm FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/~)jiijWl!i:JN#ICH IS
<br />
<br />:::::::~:::::~TORY FOR VITAL RECORDS. . _~~.~-,,~,
<br />
<br />FEB 0 2 2006 20060 1319 ~r,..itA1JL.FY:$. @F'-~R
<br />ASsisTANT STAtE, BMGiSrRAR
<br />LINCOLN, NEBRASKA H~LTH-~NO""lJM:AiJSgFW/~ES
<br />I .f' '-.> '--':~ ~i:;_cE</ .,;,-
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERV1CESF1NANC~ANlisurI?ORT
<br />CERTI~_GATE OF DEATH . . 6? 0703
<br />
<br />~
<br />
<br />
<br />1. DECEDENT'S.NAME (First,
<br />Thomas
<br />
<br />Middle,
<br />Ron~l4
<br />
<br />Suffix)
<br />
<br />2. SEX
<br />
<br />Ma 1 e_
<br />50. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />LaSI,
<br />Stuart
<br />
<br />Jan. 28
<br />
<br />20Q_fL__
<br />
<br />6. DATE OF alRTH (Mo., Day, Yr.)
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE-Last airlhday 5b. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />91
<br />
<br />April 29, 1914
<br />
<br />Central City, Nebraska
<br />
<br />7. SOCIAL SECURITY NUMaER
<br />
<br />8a. PLACE OF DEATH
<br />1::lQ.SflIAl.;
<br />
<br />o Inpatient
<br />
<br />QlliEB: ~ Nursing Home/LTC 0 Hospica Faclllly
<br />
<br />Sb. FACILITY-NAME (If not .institutioll, give $Ire~t and number.!
<br />
<br />U ERIOulpalienl
<br />
<br />Q D~cedenl'~ Home
<br />
<br />Grand Island
<br />
<br />__Ne br a ska__V p 1- p r A TJ.8-_Ho m
<br />8c. CITY OR TOWN OF DEATH (Include Zip Coda)
<br />
<br />o CO'I 0 Other (Specify)
<br />-- m_~NTYOFDEAiH-u-
<br />
<br />I ~_~H.ll
<br />
<br />_~~~::ORTOWN
<br />
<br />GrAnn Tq'l::t.n.d..-
<br />9a. RESIDENCE-STATE
<br />
<br />688r -
<br />9b. COUNTY
<br />" Hall
<br />
<br />9g.INSIDE CITY LIMITS
<br />
<br />I;iJ YES 0 NO
<br />
<br />
<br />2300 Wes.J:-__ Capi tal A venu_e...__
<br />loa. MARITAL STATUS ATTtME OF DEATH ]{I Married U Never Married lOb. NAME OF SPOUSE (Firsl, Middle, La,l, Suffix) If wile, give maiden name.
<br />
<br />o Married, but .eparated 0 Widowed U Divorced 0 Unknown
<br />
<br />Eileen Becker
<br />
<br />11. FATHER'S.NAME (Firsl,
<br />John
<br />
<br />Last,
<br />
<br />12. MOTHER'S-NAME (First,
<br />
<br />Middle,
<br />
<br />Maidan SUrname)
<br />
<br />Middle,
<br />
<br />Suffix)
<br />
<br />Stuart
<br />
<br />E d.lJ_1l Ma e
<br />
<br />~hittemore
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />13. EV~R IN U.s. ARMED FORCES? Give dales ot service if yes. 14a.INFORMANT-NAME
<br />(Yes, no, orunk.)Y e.~ Ii~~ -:-1943___J il p.p.n S t lla r t
<br />15. METHOD OF DISPOSITION 16e. EMaALMER.SIGNATURE
<br />
<br />E::LIGENSE NO.
<br />
<br />CITY !TOWN
<br />
<br />16c. DATE (Mo" Day, Yr. )
<br />
<br />_JAn
<br />
<br />o Burial 0 Donation
<br />
<br />_---D-_Ot embalm~d
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />'"\ n. ? n Q.6..__.
<br />STATE
<br />
<br />x:K::remation 0 Enlombmet11
<br />
<br />o Removal 0 Olher (Speclly) C e n t r a 1 Neb r ask a ere mat ion I G i b bon, Neb r ask a
<br />
<br />.I
<br />18. PART I. Enter tho ohAln ot .v,;nl...dl.;,....~ Injurle., or ~ompll08d,;;,,;..lh.t directly cilJledme 'd.eth. b 1WT .riter I.,mln.t ev.nt. .uch .. cardl.o a"eBl,
<br />respiratory arrest, or ventricular flbrlllation wilhoul showing the etiology. DO NOT ABBREVIATE, Enter only one cause on a line. Add additional lines if necessary.
<br />
<br />IMMEDIATE CAUSE;
<br />
<br />onsellO death
<br />
<br />IMMEDIATE CAUSE (Flnel
<br />disease or condition resulting
<br />Indealh)
<br />
<br />~_l:"g.io~.E?Elpiratory Failure_.___
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />24 Hours
<br />
<br />onsello death
<br />
<br />Sequ~nllally list conditions, If
<br />any, le.dlng 10 the cau.ellsled
<br />onllnl:!lI.
<br />Enler 'h. UNDERLYING CAUSE
<br />(di..a.e or inlury Ihollnlllaled
<br />the evenls re,ulling In dealh)
<br />lAST
<br />
<br />(b) Weight lDss and Obt1.mdation
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Dehydration
<br />
<br />17 Days
<br />
<br />on.ello deeth
<br />
<br />(c)
<br />
<br />Parkinson's Disease
<br />
<br />15 Years
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF;
<br />
<br />Ons.llo dealh
<br />
<br />(d)
<br />
<br />20. IF FEMALE:
<br />o Nol pregnanl wllhln past year
<br />o Pregnanl at lime of de.th
<br />o Not pregnant, bUI pregnant wilhln 42 days of dealh
<br />o Not pregnant, but pregnant 43 days to 1 year before dealh
<br />I:) Unknown if pregnant within the past year
<br />
<br />210. MANNER OF DEATH
<br />;e{Natural 0 Homicide
<br />
<br />o AccidenlO P.ndlng Invesligation
<br />
<br />o Suicide 0 Could nol be determined
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />U YES Q( NO
<br />
<br />21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDlTIONS.Condillons conlrlbullng 10 Ihe dealh bul nol re,ulllng in the undorlying cause given In PART I.
<br />Lf'My Body Dementia, DJD, Anemia, CAD, COPD, CRr
<br />
<br />o YES
<br />
<br />}{1M NO
<br />
<br />o Passenger
<br />o Pedestrian
<br />
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES 0 NO
<br />
<br />o Olher (Specity)
<br />
<br />22d.INJURY AT WORK?
<br />
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />22b. TIME Of INJURY .;1U. PLACE-OF INJURY.Al homo, larm, ,Ir.el, factory, oltlc. building, construction site, etc. (Specify)
<br />m
<br />
<br />o YES 0 NO
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />24e. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />;;l:)-
<br />...~!!i
<br />.egg;:
<br />""'~
<br />.I!>-
<br />t~~::J
<br />E .,,~ Z
<br />00: 0
<br />"w
<br />.8z=>
<br />00
<br />ea:u
<br />) Sa
<br />
<br />m
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAO
<br />m
<br />
<br />24.. On Ihe basis of examlnallon and/or inve'ligation, In my opinion dealh occurred al
<br />the lime, date and place and due to Ihe cause(s) staled. (Signalur. and Title) l'
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TOTHE DE TH?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />Nol Applicable if 26a is NO 0 Y~S 0 NO
<br />
<br />_c:J_~~~_.H_ NO _9_~~~~~~ 0 UNKNC!..\^i!:! ...... __~Y~!____.___~_!:!~. ...._
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. or Print)
<br />M.A. Tompkins, M.D., Grand Island Veterans Hane, Grand
<br />
<br />Island, NE 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED ay REGISTRAR (Mo., Day, Yr.)
<br />
<br />JAN 3 1 Z006
<br />
|