|
<br />q\
<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 RECQRD ,QHFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSTI~ii;"(Ij)f/;'~CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.;1I-il;;"':/:;j.~~;,-,
<br />
<br />DATE OF ISSUANCE JV7''';:71;A~EY:os;oC;~~~
<br />
<br />I="EB 1 R ZOOF 200601879 ASSlStAN1-s-iA'rti11l!GlSTRAFi'
<br />LINCOLN, NEBRASKA HEAif,H'1ff!D HWANSER..~i!;E$
<br />
<br />". . -"o~~~::cl~~17f~':(~~~}7'
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FiNANCEAND $tI:f1PoRT
<br />CERTIFICATE OF DEATH . .. n
<br />.~~-~ -..-
<br />
<br />21322
<br />
<br />"'J
<br />
<br />
<br />DECEDENT'S.NAME (Firs!. Middle, Lasl, Suffix) 2"SEX 3" DATE OF DEATH (Mo., D.y, Yr")
<br /> Helen Jane Ross Female Februa~y 7, 2006
<br /> ..,-,,-
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF 61RTH 5.. AGE-La't Birthday 5b. UNDER 1 YEAR 50. UNDER 1 DAY 6" DATE OF BIRTH (Moq Day, Yr")
<br /> (Yrs") MOS" DAYS HOURS MINS"
<br />Red Cloud, Nebraska 83 April 6, 1922
<br />
<br />___H_ I
<br />7" SOCIAL SECURITY NUMBER 8a PLACE OF DEATH
<br />506-22-4210 ~
<br />8b fACILITY NAME (If not InstitutIOn I give street and numbAr)
<br />
<br />Wedgewood Care Center
<br />
<br />o Inpstlent
<br />
<br />QlliEB:
<br />
<br />Kt Nursing Hom./LTC 0 Hospice Facility
<br />
<br />U ERlOulpatient
<br />
<br />U Decedent's Home
<br />
<br />Nebraska
<br />
<br />-] 9b"COUNTY Hall
<br />
<br />o DY\ 0 Other (Specity)_.
<br />
<br />'~d"COUNTYOFDEATH
<br />Hall
<br />-", -
<br />9c" CITY OR TOWN
<br />
<br />8c" CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />
<br />Island
<br />
<br />9UIP~~~~~_ 199~-S~:~~ITY~iM~~
<br />
<br />1 Ob" NAME OF SPOUSE (First, Middle, Last, Suffix) If wile, 91ve maldan name.
<br />
<br />
<br />9d" STREET AND NUMBER
<br />1609 N. Kruse
<br />
<br />o Married, but separated 0 Widowad iXDivoroed 0 Unknown
<br />
<br />11" FATHER'S.NAME (Firs!.
<br />
<br />Albert
<br />
<br />Middle,
<br />
<br />Last, Suffix)
<br />Shimic
<br />
<br />'1:_2"
<br />
<br />MOTHER'S.NAME (First,
<br />ErnriJ.a
<br />
<br />Q[Cremation 0 Enlombmant
<br />
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />- '--t:ENSE NO,
<br />
<br />
<br />CITY /TOWN
<br />
<br />Middle, Maiden Surnama)
<br />
<br />Korbelik
<br />
<br />"3;' .. -, 14b_RE~~~NSHIPT.O-DEC.E.. ~ENT
<br />
<br />16c, DATE (Mo., D.y, YL)
<br />__"!ebruary 8, 2096
<br />
<br />STATE
<br />
<br />13. EVER IN U.S" ARMED FORCES? Give dales 01 service il yes. 14..INFORMANT-NAME
<br />(Yas, no. or unk.) No Jerry Ro s s
<br />
<br />
<br />o Burial
<br />
<br />U Donation
<br />
<br />16a. EMBALMER-SIGNATURE
<br />NOT EMBALMED
<br />
<br />15" METHOD OF DISPOSITION
<br />
<br />o Remov.1 0 Other (Speclly)
<br />
<br />Westlawn Memorial Park Crematory
<br />
<br />Grand Island, NE
<br />
<br />.,"
<br />
<br />
<br />
<br />
<br />17a. FUNERAL HOME NAMIO AND MAILING ADDRESS (Street, City orTown, Stale)
<br />Apfel Funeral Home 1123 West Second,
<br />
<br />Grand Island, NE.
<br />
<br />18. PART I. Enler Ihe chain of Bvents--diseases, Injuries, or compljcations.~that dIrectly caused the death. DO NOT enter terminal events such as cardIac arrest,
<br />raspiratory arrest, or vantricular IIbrlllation without showing the etiology" DO NOT ABBREVIATE. Enter only one cause on a lin.. Add addltlonallinas if necess.ry.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMeDIATe CAUSE (Ftn'l
<br />disease or condition resulllng
<br />In death)
<br />
<br />Sequentially lI.t condition., If (b)
<br />.ny,IB.dlngtothecau.ellsted DUIO To.OR'/lS /I'CONSEQUENCE OF:
<br />on IIn. ..
<br />Enter the UNDERLYING CAUS.
<br />(disease or Injury thai initialed (c)
<br />theavenloreoulflng Indo.th) DUE TO, OR AS A CONSEQUENCE OF:
<br />I.ASf
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />(a) ~~/~/V
<br />----...-.."".."..-....-".. - "",, ........--
<br />DUE TO. OR AS A CONSEQUENCE "
<br />
<br />onset to death
<br />
<br />
<br />~.
<br />a
<br />on,et to death
<br />
<br />onset to death
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />20. IF FEMALE: 21'~M NEROFDEATH 21b" IFTRANSPORTATION INJURY
<br />I-. Natural 0 Homicide D Drlver/Op.rator
<br />~ Not pregnant within past year
<br />o Pregnanlal time 01 death 0 Accid.nlD Pending Inve'lig8110n U Passonger
<br />o Not pregnanl, but pregnant within 42 days of d..th U Suicldo 0 Could nol be determined 0 Pedestrian 21d, WERE AUTOPSY FINDINGS AVAILABLe TO
<br />o Not pregn.nt, bul pregn.nt43 day. to 1 yoar belore de.th 0 Olher (Spacily) COMPLETE CAUSE OF DEATH?
<br />o Unknown if pregnanl within the past year 0 YES~' NO
<br />-22.. DATE OF INJURY (Moq Day.Y;~j-22b" TfME OF INJUR: -. 22c, PLACEOFINJURY.At home, lerm, streat: factory, office building, oonotr~ction ~;;;,-.tc, (Speoil~---'
<br />
<br />22d.INJui;YATWc;RK?~.' DE. .SCR'IBE HOW INJURY OCCURRED
<br />U YES CJ NO _I ._.._
<br />221.. LOCATION OF INJURY - STREET & NUMBER, APT NO.
<br />
<br />I". W~ ""'''''''''''"
<br />OR CORONER )9NTACTED?
<br />
<br />DYES /=J NO
<br />.- " , ----
<br />210. WAS AN AUTOPSY PERFORMED?
<br />
<br />____n_____._ _..__ ..._.,._ --
<br />lB. PART II.. OTHER_~,GhANT CONDITIONS-Conditions contributing to the death but not r.e'Ultlng In the UndarlYin~ c~lven in PART I..
<br />t::" ~~/jS #'0"'" .,...,.., I;"" ~,(/ P-r ;:::?"'~/ "'-j t C~ .-
<br />
<br />U ns
<br />
<br />~O
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />m
<br />
<br />~H
<br />a:Ui!3
<br />]!H
<br />a. 11. C ~
<br />E8''''~~
<br />a:z
<br />1l!l!i5
<br />~~o
<br />81;
<br />
<br />
<br />24b, TIME OF DeATH
<br />
<br />23a. DATE OF DEATH (Mo" Day, Yr.)
<br />Febru!,!,ry 7,2006
<br />
<br />23b" DATE SIGNED (Mo" Day, Yr.)
<br />February 8 2006
<br />
<br />m
<br />
<br />24d" TIME PRONOUNCeD DEAD
<br />m
<br />
<br />24e. On Ihe basis of examination and/or investigation, in my opinion dealh occurred at
<br />the time, date and place and due to the ceuse(s) stated, (Signatura and Title) ,.
<br />
<br />.~l
<br />
<br />26a, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />__CJ..Y~S.. 0 NoD PROBABLY r;i UNKNO\'iN . DYES ~O .....
<br />27" NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN,-CORONER'S PHYSICIAN OR COUNTY ATTORNEY)' (Type or Print)
<br />Jane McDonald M.D. 800 N. Alpha Ave., Grand Island,
<br />
<br />26b. WAS CONSENT GRANTED?
<br />Not AJ'plioable 1126a is NO 0 YES INO
<br />
<br />NE.
<br />
<br />68803
<br />
<br />2Ba. REGISTRAR"S SIGNATURE
<br />
<br />
<br />2eb. DATE FILED BY REGISTRAR (Moq Day, Yr.)
<br />
<br />FEB 1 4 2006
<br />
|