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<br />
<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 ORIGIN~.REeORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL sT.ArJSt/cssE:qT1~ WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. .. i .~.'Mit.Y. ~.,..;.j;j)..7.'."'",., ~',~ 'j~=-ll:~
<br />
<br />DATE OF ISSUANCE .~~ii~j:'f;:'C=~f;"
<br />
<br />MAR 0 9 2006 2006 0 3~ 31 ~~ ~dsliiNT~f; $~/~=~:
<br />LINCOLN, NEBRASKA WEALrH ANDHUMAtJ SEffVlCES
<br />
<br />
<br />STATE OF NEBRAsKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE ANll~ciPPORT
<br />.. ..... CERTIFICAIE~9fDEATH .. . ....... "0.6.22382
<br />(First, Middle, Last, Sulflx) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Joseph Sid O'Hare Male March 3. 2006
<br />
<br />1. DECEDENT'S.NAME
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a. AGE. Last Birthday 5b. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />
<br />Palmer, NebJ:'..!!EJka 79
<br />
<br />7 SOCIAL SECURITY NUMBER' - .ia PLACE OF DEATH
<br />
<br />505-34-4813 ~~L
<br />
<br />8b. FACILITY. NAME (II not Instltullon, give streel and number)
<br />
<br />
<br />1508 West Division Street
<br />
<br />5c. UNDER 1 DAY
<br />HOURS J. MINS:'
<br />
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />~ugust 28,
<br />
<br />1926
<br />
<br />o Inpatient
<br />
<br />QTI:illJ:
<br />
<br />o Nursing Home/LTC 0 Hospice Facility
<br />
<br />lSj Decedent's Home
<br />
<br />o ER/Outpatient
<br />
<br />ODOA
<br />
<br />t!l Othor (Specllyi
<br />8d. COUNTY OF DEATH
<br />
<br />Be. CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />Grand Island
<br />9a. RESIDENCE.STATE
<br />
<br />68801
<br />
<br />.._..._ .19b~;~~~~
<br />
<br />Hall
<br />
<br />90. CITY OR TOWN
<br />Grand Island
<br />"'-T~APT.NOn 916Z; ~~D;
<br />
<br />
<br />lOb. NAME OF SPOUSE (First, Middle, Last, Sulllx) If wile, give maiden name.
<br />
<br />9g. INSIDE CITY LIMITS
<br />~ YES 0 NO
<br />
<br />Nebraska
<br />9d. STREET AND NUM8ER
<br />
<br />1508 West Division Street
<br />-IDa MA'riiTAL STATUS ATTIME OF DEATH O!M'-r;;';-ONever M'a~;i;d
<br />
<br />o Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Bet ty Puncochar
<br />
<br />11. FATHER'S.NAME (First,
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />Suflix)
<br />
<br />12. MOTHER'S.NAME (First,
<br />J' at r ~~!.~.
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />
<br />
<br />O'Hern
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />W1.1liaIIL_, F.
<br />13. EVER IN U.S. ARMED FORCES? Give dates 01 service II yes.
<br />(Yes, no, or unk.) No
<br />
<br />O'Hare
<br />
<br />Wife
<br />16c. DATE (Mo.. Day, Yr.)
<br />Marc.:h 4, 2006
<br />
<br />STATE
<br />
<br />15 METHOD OF DISPOSITION f:6a EMBALMER.SIGNATURE
<br />o Burial o Donalion Not Embalmed
<br />IX".."" 0 '"..~." ." ".m"" ,",".m", '" ~" COC.""
<br />
<br />o Removal o Other (Specify) Westlawn Crematory
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />
<br />I=SE NO.--'.u
<br />
<br />--..-...-..
<br />CITY /TOWN
<br />
<br />Grand Island
<br />
<br />PART I. Enter the chain of events..diseases, Injuries, or compllcallonS--lhat dIrectly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />r.'piralory arrest, or ventricular IIbrillatlon wlthoul showing Ihe etiology. DO NOT ABBREVIATE. Entar only one causa on allne. Add additional lines If nsceasary.
<br />IMMEDIATE CAUSE:
<br />
<br />I
<br />I
<br />
<br />t onset 10 dAalh
<br />I
<br />
<br />L.- 24 ~ f'\ ~
<br />
<br />I onsel to dealh
<br />
<br />IMMEDIATE CAUSE (Flnol
<br />disease or condition resulting
<br />in death)
<br />
<br />
<br />'_ ~ ~. ( G_.._
<br />
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />u. ",,-,L
<br />I
<br />I
<br />I
<br />
<br />~.
<br />
<br />'- vv-.. (,
<br />
<br />..-.... 4 VV\0'v-- \~ J
<br />
<br />c..J. \ ~
<br />
<br />Sequenllally 11,1 conditions, If (b) (') \,)y\. _. ":) rY\ 1\ ~ \
<br />any, leading 10 the cause 1i,led DUE TO, ORAS'ACONSEQUENCE OF:-'
<br />on line II.
<br />Enlerlhe UNDERLYING CAUSE
<br />(dlseo.e or Injury Ihallnltloled (c)
<br />the events resulting In d~ath)
<br />IJ\ST
<br />
<br />CJ\
<br />
<br />onssl to death
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF.
<br />
<br />onset to death
<br />
<br />:Ii
<br />;~li:.
<br />,~\' '~I'
<br />'.'.' ..........
<br />l\' .'
<br />;"~;
<br />1
<br />.0.
<br />~'
<br />u
<br />,'.IJ
<br />
<br />(d)
<br />
<br />-=O;?~TCO~~'~~:~L=~'Cf\"~:'"B~;:::.;;rt'
<br />
<br />
<br />20. IF FEMAL~: 2ta. MANNER OF DEATH 21b.IF TRANSPORTATION INJURY
<br />o Not pregnant within past year )E(.t!atural 0 Homicide 0 Driver/Operator
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />o YES ~ NO
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />DYES J4NO
<br />
<br />I:J Accldontl:J Pending Inveallgollon
<br />
<br />o Passenger
<br />o Pedestrian
<br />o Other (Speclly)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABlE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />o Pregnanl al1ime 01 death
<br />o Nol pregnant, but pregnant within 42 days 01 death
<br />o Nol pregnant, but pregnant 43 days 10 1 year before death
<br />o Unknown if pregnant wllhln the pasl year
<br />
<br />o Suicide 0 Could not be determined
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY.At home, farm, street, tactory, oftice building, construction site, otc. (Specify)
<br />m
<br />-22dINJURY-ATWO~2~ DESCRIBE HOW INJURY OCCURRED
<br />o YES I:J NO I
<br />
<br />221. LOCAl ION Of INJURY. STREET & NUMBER. APT NO. CllYfTOWN
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (..MO., Day, y/r.) ~
<br />:.>, 1/ /", )
<br />J (...I ,
<br />.. ............._.__.....J. ...... _...... ...
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />). '-I ) ;30
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />z>-
<br />~~~
<br />llW'"
<br />l!~~
<br />c. Jl. ill: :J
<br />E Y' >- z
<br />8ffi!;;O
<br />"z=>
<br />.cOO
<br />~a::U
<br />815
<br />
<br />m
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis 01 examination and/or invastigatlon, in my opinion daath occurred at
<br />the time, data and placa and due to tha causa(s) slated. (Signature and Title) T
<br />
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 Y~~_...
<br />
<br />MAR
<br />
<br />9 2006
<br />
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