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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~lJJ~CE1flQ Qf:{FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAM't]~t!; SEQTlqN;"WHICH IS
<br />
<br />
<br />::~;()::C:T;~1~N80:E2/7ioOoR5Y FOR VITAL RECORDS. ~~ER
<br />LINCOLN, NEBRASKA 200 6 0 3 5 4 1 ~lI~~ ~:~~~~~~~~
<br />u
<br />. -
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANGE"'AND SUPPORT 0 5
<br />____u____CEB_T1FICATE OF DEATH
<br />
<br />11161
<br />
<br />DECEDENT'S.NAME (Fir.1,
<br />Irma
<br />
<br />Middle,
<br />Lucille
<br />
<br />Last,
<br />Thompson
<br />
<br />Suffix)
<br />
<br />2_ SEX
<br />Female
<br />
<br />3_ DATE QF DEATH (Mo" Day, Yr.)
<br />October 4, 2005
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE-Lest Blrlhday 5b. UNDER 1 YEAR
<br />(Yrs_) MOS_ DAYS
<br />84
<br />
<br />Sc. UNDER 1 DAY
<br />HOURS MINS_
<br />
<br />6. DATE OF BIRTH (Mo., Dey, Yr.)
<br />
<br />Hamilton County, Nebraska
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />508-10-2786
<br />
<br />April 26, 1921
<br />
<br />ea_ PLACE OF DEATH
<br />tLQSf.lIAL: 0 Inpatienl
<br />
<br />9l!icB: :JB Nur;lng Home/lTC 0 Hospice Facility
<br />
<br />eb. FACiliTY-NAME (If not Instllullon, give street end number)
<br />
<br />o ER/Qutpalient
<br />
<br />o Decedent's Home
<br />
<br />Wedgewood Care Center
<br />
<br />OM
<br />
<br />o Olher (Speolly)
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />
<br />ed_ COUNTY OF DEATH
<br />Hall
<br />
<br />Hall
<br />
<br />
<br />91. ZIP CODE
<br />
<br />9g. INSIDE CITY LIMITS
<br />Xl YES 0 NO
<br />
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />
<br />9b. COUNTV
<br />
<br />9d. STREET AND NUMBER
<br />
<br />523 West 14th. Street 68801
<br />lOa MARITAL STATUS AT riME OF DEATH :JP M;;;;;~d D-N-ever Marrled-- tOb NAME OF spousi(F;r;;:M;d;;i;, Last, SUffIX) Il;te, g,~e-~;'d~n-n~m~ --- - - ------
<br />
<br />o Married, but separated 0 Widowed 0 Divorced 0 Unknown R 0 s c 0 e B 1 a i neT horn p son
<br />
<br />"~- - ----
<br />Lasl, Suffix) 12. MOTHER'S-NAME (Fir,1, Mlddla, Maiden Surnama)
<br />~O...!:.~_~___ ___~_~..!S U~_!:..Cl____._E '___~_~':l~ s e r ~e ~ 1"_
<br />
<br />11. FATHER'S.NAME (First,
<br />Ernest
<br />
<br />Middle,
<br />
<br />F.
<br />
<br />(Yas, no, or unk.)
<br />
<br />no
<br />
<br />
<br />Thorn son
<br />16b. LICENSE NO.
<br />
<br />14b. RELATIONSHiP TO DECEDENT
<br />Husband
<br />
<br />13. EVER IN u.s. ARMED FORCES? Give dates of service if yes.
<br />
<br />15. METHOD OF DISPOSITION
<br />LXBurlal U Donelioo
<br />
<br />160. DATE (Mo.. Day, Yr.)
<br />
<br />U Cramallon U Entombmant
<br />
<br />1Q]~
<br />CITY / TOWN
<br />
<br />l!::..t_a.he_L3 ._2QQ5
<br />STATE
<br />
<br />o Removel 0 Olher (Speolly)
<br />
<br />Grand Island.
<br />
<br />Grand Jsl_~l1Q City Cemetery
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (S"eel, City or Town, State)
<br />All Faiths Funeral Home
<br />
<br />18. PART l. Enter the QMln.m~~--djseases! injuries, or compticationSnthat directty caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />raspiratory arrast, or vantrlcular fibrillation wllhoul showing the etiology. DO NOT ABBREVIATE. Enter only one cau,e on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />
<br />onset to death
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl....e or cond~ion re.ultlng
<br />In dooth)
<br />
<br />(e) C'\\n.Y'\\ ~_!,Q..'"",lIo...\ ,~u. ~ \~
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I \.9 MtYlJh,J
<br />
<br />on.et to dealh
<br />
<br />Sequentially list conditions, if
<br />any, leading to the eam;ie lI$ted
<br />on line a.
<br />Enlor Iho UNDERLYING CAUSE
<br />(disease or Injury that in~iated
<br />the ovonlo reoulllng in death)
<br />LASf
<br />
<br />(b) \-\ f N
<br />
<br />\leQ\r:>
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset 10 dea.th
<br />
<br />(c) 'P~'J\~ ~la,L\d(.....-
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />2.. wlcs
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to tha dealh but not rasultlng In the undarlylng causa givan In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />o YES [i{"NO
<br />
<br />o Pragnant at tlma ot daath
<br />U NOI pragnanl, but pregoonl wllhln 42 deys of dealh
<br />o Nol pregnant, but pregnanl43 days 10 1 year belore d..th
<br />o Unknown if pregnanl wllhin Ihe past year
<br />
<br />21a. MAN.tll'Ji OF DEATH
<br />\:I Natural 0 Homlcld~
<br />
<br />~ccldentO Pending Investigation
<br />
<br />o Suicide 0 Could not ba delermlned
<br />
<br />2tb.IFTRANSPQRTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Drlver/Operalor
<br />
<br />o Passenger
<br />I:l Pedsstrlan
<br />o Othar (Specify)
<br />
<br />I:l YES
<br />
<br />U1fo"
<br />
<br />2td. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES W NO
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />
<br />22c. PLACE OF INJURY.AI homa, farm, straet, factory, olllea building, construction sita, ale. (Spaclfy)
<br />Home
<br />
<br />22d_INJURY AT WORK?
<br />
<br />22a_ DESCRIBE HOW INJURY OCCURRED
<br />
<br />o YES cXNo
<br />
<br />Pt fell
<br />
<br />
<br />out of bedt:Q_~se l>_~th.:r_ootll_
<br />CITYITOWN
<br />
<br />ST-"fE
<br />
<br />ZIP CODE
<br />
<br />221. LOCATION OF INJURY. STREET & NUM8ER, APT. NO.
<br />
<br />____8JlQ_13__tgeger Dr..
<br />23a. DATE OF DEATH (Mo.. Dey, Yr.)
<br />October 4, 2005
<br />
<br />Gr aIHL.ll>land~
<br />
<br />NE
<br />
<br />68803
<br />
<br />24a. DATE SIGNED (Mo_, Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
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<br />a.I::L. ia:J; ::i
<br />!i~t~
<br />u UJ Z
<br />o>z::>
<br />.000
<br />~a:U
<br />o~
<br />UO
<br />
<br />m
<br />
<br />23b. DATE SIGN~,o (Mo.. Day, Y;l"
<br />lu-5..0.;)
<br />
<br />23c. TIME OF DEATH
<br />11: 17
<br />
<br />24c_ PRONOUNCED DEAD (Mo_, Day, Yr.)
<br />
<br />24d_ TIME PRONOUNCED DEAD
<br />
<br />m
<br />
<br />23d. To tho bosl of my knowladga, death occurred at the time, dale end place
<br />and due to tha eause(.) slatad_ (Signatura and Titla) T
<br />
<br />v) ~ V"'.
<br />
<br />.24e. On the basis of examination andJor investigation, in my opinion death 'occurred at
<br />Ihe time, dale and place and due to Ihe causers) Slated. (Signelura and Title) T
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />
<br />o YES ~O W PR08ABLY LJ UNKNOWN 0 YES ~ Not Applicable if2~~i..Ng_ 0 YES ~O
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSiCiAN ciR'COUNTY Aii:oR'NEY)(Typeo,Printj
<br />
<br />Jennifer Kin M.D. 729 North Grand Island Nebraska 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b_ DATE FILED 8Y REGISTRAR (Mo_, Day, Yr.)
<br />
<br />OCT
<br />
<br />17 2005
<br />
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