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<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 RECO_RDONfILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC.S-=-f!ECTiqN~Wit!PH IS
<br />
<br />
<br />~;;:;~;c:TORYFOR WTAL RECORDS. ~i~~
<br />ASS!.$TANT irrAtEiRl=~I$TFfAFi"
<br />HEALTH 'AND HUAfANs6.RJlCES'
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />200604184
<br />
<br />
<br />Last,
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER. V. IC. ES FI.N. ANCE ANDSUPPOI}\,~ 2' 3' ",4:. 2'.9' .','
<br />CERTIFICATE OF DEATI:I.. n.____ J.Jh:ll _ _~_
<br />Sultlx) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 20, 2006
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
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<br />23a, DATE OF DEATH (Mo.. Day, Yr.)
<br />March 20, 2006
<br />
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<br />81;
<br />
<br />1. DECEDENT'S-NAME (First,
<br />Marshall
<br />
<br />Middle,
<br />William
<br />
<br />Forst
<br />
<br />MalE.'
<br />
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />
<br />E.'cE'mbE'r 18,1920
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE-Last Birthday
<br />
<br />(Yrs.) 85
<br />
<br />6, DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />IXI Inpatient
<br />
<br />QJlJel: 0 Nursing Home/LTC 0 Hospica Facility
<br />
<br />LawrE'ncE', NE'braska
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />8a. PLACE OF DEATH
<br />
<br />o ER!OutpaUant
<br />
<br />o Decedenl's Home
<br />
<br />522-18-3553
<br />
<br />l:Jilll.E'.lIlIL:
<br />
<br />DOClo\
<br />
<br />U Other (SpecitYL_.___.___.
<br />
<br />8b. FACILITY-NAME (If nol Institution, give street and number)
<br />St. Francis ME'dical CE'ntE'r
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island
<br />
<br />68803
<br />
<br />8d. COUNTY OF DEATH
<br />
<br />Hall
<br />
<br />9C. CITY OR TOWN
<br />
<br />1!'~J2r .118 k a _____""" ___~___l!<iLt;t_,._..",.
<br />9d. STREET AND NUMBER
<br />1734 DorE'E'n St.
<br />
<br />
<br />9g. INSIDE CITY LIMITS
<br />Xl YES 0 NO
<br />
<br />
<br />23c. TIME OF DEATH
<br />8:17 P m
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />9a RESIDENCE. STATE
<br />
<br />9b. COUNTY
<br />
<br />9f. ZIP CODE
<br />68803
<br />
<br />1 oa. MARITAL STATUS AT TIME OF DEATH 00 Married 0 Never Married
<br />
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wile, give maiden name.
<br />Norma ArtE'rburn
<br />
<br />12. MOTHER'S.NAME (First,
<br />Anna
<br />
<br />Middle,
<br />
<br />Melden Surname)
<br />Schwynock
<br />
<br />o Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />
<br />11. FATHER'S.NAME (First, Middle,
<br />
<br />BE'njamin
<br />
<br />Last,
<br />Forst
<br />
<br />Sultlx)
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Forst
<br />16b. LICENSE NO.
<br />J328
<br />
<br />W_tJe
<br />16c. DATE (Mo.. Day, Yr. )
<br />March 24, 2006
<br />
<br />1 "EVER IN U.S. ARMED FORCES? Give dale, of ,ervlea If yes. 14a.INFORMANT-NAME
<br />(les~~orUnk) 1/7/42-9/13/45 Norma M.
<br />15. METHOD OF DISPOSITION
<br />asi Burial 0 Donation
<br />
<br />o Cremallon 0 Enlombment
<br />
<br />
<br />CITY / TOWN
<br />BlUE' Hill
<br />
<br />STATE
<br />NE'braska
<br />
<br />o Removal
<br />
<br />BluE' Hill
<br />
<br />CE'mE'tE'ry
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreel, City or Town, State)
<br />All Faiths FunE'ral HomE',2929 S.
<br />
<br />
<br />18. PART I. Enler the chain 01 events..dlseasBS, Injuries, or compllcatlonsnthat directly caused the death. DO NOT enter terminal events suoh as cardiac: arrest,
<br />respiratory arrest, or venlricular IIbrlllallon without showing the etiology. DO NOT ABBREVIATE. Enler only one cause on a line. Add addlllonalllnee if necessary.
<br />
<br />I
<br />I
<br />
<br />I onset to death
<br />I
<br />I
<br />----L...
<br />I onSet to death
<br />I
<br />I
<br />I
<br />I onset to death .
<br />I
<br />I
<br />
<br />_"._._.__....__".._'"_.__.~____~_J...._.........
<br />I onsello dealh
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDlTIONS.Condllion. contrlbullng to the deeth bUI not resulling In the underlying cause given In PART I.
<br />
<br />o NO
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />DYES
<br />
<br />21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />IJ Driver/Operator
<br />
<br />o Passenger
<br />
<br />DYES
<br />
<br />~O
<br />
<br />o Other (Specify)
<br />
<br />IMMEDIATE CAUSE (Final'
<br />disease or condition ..suiting
<br />In death)
<br />
<br />IMMEDIATE C~'SE:
<br />
<br />F
<br />(a) / ,.......k.......-e~_,.,..-'.............'.n.~-n. --"1...--\.' :'-./~,m'('t
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />o Pedestrian
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />Sequentially list condlllons, If
<br />any, leading 10 the causellSled
<br />on line I!!I.
<br />Enter the UNDERLYING CAUSE
<br />(dls.ase or Injury that Initiated
<br />the events resulting In death)
<br />lAST
<br />
<br />(b)
<br />
<br />o Olher (Specify)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY.AI home, lerm, slreel, fectory, office building, construction slla, etc. (Specify)
<br />m
<br />22d.INJURY ArWORK? [22e DESCRiBE HOW INJURY OCCURRED
<br />DYES ONO'
<br />--~_..._."
<br />22'- LOCATION OF INJURY. STREET & NUMBER, APT. NO. CITYITOWN
<br />
<br />\
<br />
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(c)
<br />---------..-.--.--.,
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />20. IF FEMALE:
<br />IJ Nol pregnant wllhin paS! year
<br />o Pregnanl alllme of dealh
<br />o Nol pregnant, but pregnant within 42 days 01 death
<br />o Not pregnanl, but pregnant 43 day. to 1 year before death
<br />o Unknown if pregnanl wllhin the past year
<br />
<br />21a. MANNER OF DEATH
<br />~atural 0 Homicide
<br />
<br />o AccidenlD Pending Invesllgellon
<br />
<br />o Suicide 0 Could not be determined
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />24e. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24a. On the basis of examination and/or lnvesllgatlon, In my opinion death occurred at
<br />the time, dale and place and due 10 the causers) slaled. (Signelure and Tille) 'f"
<br />
<br />25. DIDTOSACCO USE CONTAIBUT 26a. HAS ORGAN OR TISSUE DONATION SEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />'- I
<br />o YES ...J<1I:'~O. ....9 PROBABLY__ 0 UNKNOWN lJ YES _ ... .~_~. Not Applicable 1126als NO_9. YES 0 NO
<br />27. NAMI] TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Prinl)
<br />GorUon HrnicE'k, M.D., 729 N.Custe AVE'.,Grand Island, Nebraska 68803
<br />
<br />28b. DATE FILED SY REGISTRAR (Mo.. Day, Yr.)
<br />
<br />MAR 3 0 2006
<br />
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