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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 RECORD ON FILE WiTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSTlC.$.:8EC.T1GN,WWCH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS_AI' ~~ .;~. .
<br />
<br />
<br />DAT; ~~/siu;N2005 20060 46 .t 6 JV~fi~N~EY S;CO~~E~ 00
<br />~ ASSI$.TANT S'TATE REGistRAR
<br />LINCOLN, NEBRASKA HEALrH,A,,!,?!,UMAN st;RV1CES.
<br />
<br />."'{~ '~{:<.1.. ,
<br />
<br />" \
<br />"',~
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />___ CERTIFICATE OF DEATH _.__. .---o-5---D1-4-53-
<br />
<br />DECEDENT'S.NAME (First, Middle, Lasl, Suflix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />___g,~!El.~ Hen Witter MaleJ"~:r~Y 6, _2.00L
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Lasl Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo" D.y, Yr.)
<br />(Yrs.) MOS. DAYS HOURS MINS.
<br />
<br />Michi an
<br />
<br />85
<br />B.. PLACE OF DEATH
<br />
<br />1i0SPITAL:
<br />
<br />June 10, 1919
<br />
<br />o Inpatient
<br />
<br />QlI:JEfl ~urslng Ho,ne/LTC 0 Hosplc. Facility
<br />
<br />Bb. FACILITY.NAME (If not InstlMlon, giva .traat and numbar)
<br />
<br />o ER/Oulpatlent
<br />
<br />o Decedentls Home
<br />
<br />Grand Island Veterans Hone
<br />
<br />Q[O\
<br />
<br />o Olhar(Sp.cify)__._
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />Grand Island, Nebraska 68803
<br />
<br />8d. COUNTY OF DEATH
<br />
<br />.". .~tJ ~}:) r ~_s k a____
<br />9d. STREET AND NUMBER
<br />
<br />;U.QJt...Ji.~_f.i.i_.C a i ta 1 A v e n u e
<br />lOa. MARITAL STATUS AT TIME OF DEATH Married U Never Married
<br />
<br />Hall
<br />
<br />
<br />_ ._..__Iia~~_.~ounty
<br />
<br />9a. RESIDENCE.STATE
<br />
<br />9tJ. COUNTY
<br />
<br />68801
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />ltfYES 0 NO
<br />
<br />lOb. NAME OF SPOUSE (First, Middle, Lasl, Suffix) I! wlte, give maiden nama.
<br />
<br />o Married, bUI separaled 0 Widowed 0 Divorcad 0 Unknown
<br />
<br />11. FATHER'S.NAME (First,
<br />
<br />Middle,
<br />
<br />(Firsl,
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />
<br />...R.eid___.." ara
<br />13. EVER IN U.S. ARMED FORCES? Give dales 21 service II yes. 14a.INFORMANT.NAME
<br />- 9-4-43 tD ll-i8-45 -
<br />(Yes, no, orunk.) ha.r.Le.s~",wLtl_er.. ..
<br />
<br />15. METHOD OF DISPOSITION 16A. EMBALMER.SIGNATURE - ---..r;6b. LICENSE NO.
<br />
<br />QBurlAI QDonBllon Not Embalmed ----.l__._ ...
<br />
<br />~ Cremation U Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN
<br />
<br />o Ramoval U Other (Specify)
<br />
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />o.n.....-_~ .
<br />16c. DATE (Mo" Dey, Yr. )
<br />
<br />
<br />5....._
<br />
<br />STATE
<br />
<br />Central Nebraska crematic:>~__S~rvice
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Straat, City orTown, Stala)
<br />
<br />Gibbonl Nebraska
<br />--==r17b'-ZIP C~-de
<br />
<br />PART I. Enter the chain 01 evenls..dise8sBs, injuries, or compllcaUonS--lhat directly caused the dealh. DO NOT enter lerminal events such as cardiac arresl,
<br />respirAtory atrest, or ventrlculer Ilbrlllellon without showing tha atiology. DO NOT ABBREVIATE, Enter only one ceuse on a line. Add addltionAllinas it necessery.
<br />IMMEDIATE CAUSE:
<br />
<br />onsel to dealh
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In daath)
<br />
<br />(a)u~ardiorespiratory Arrest
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Inunedia te
<br />
<br />onset to daAth
<br />
<br />Sequentially tI.t condition., II (b) Pneunonia and Sepsis - Presumed
<br />.ny, I..dlng to the cau..ltst.d DUE Ti:i,ORASACO'N-SEQU'ENCE OF:
<br />on line B.
<br />Enter lhe UNDERLYING CAUSE
<br />(dl....e or Injury th.t Inltl.ted (e)
<br />the events r.sultlng In d..th) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />
<br />3- 7 Days
<br />
<br />onsal to d.alh
<br />
<br />onsello dealh
<br />
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to Ihe death but not resulting in Iha underlying csuse given In PART I.
<br />Weight loss and Cachexia; Hematochezia, etiology uridetennined;
<br />
<br />CAD with ischemia; Myocardiopathy; HI'N; Mild COPD.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTm?
<br />
<br />o YES XI NO
<br />
<br />20. IF FEMALE:
<br />o Not pregn.nl within p.st year
<br />o pr.gn.nl.t time ot da.th
<br />o Not pregnanl, bul pregn.nt within 42 d.ys 01 daath
<br />o NOI pragnant, bUI pregnant 43 days 10 1 year b.tora daath
<br />U Unknown II pregnant within the past year
<br />
<br />21a. MANNER OF DEATH
<br />~ Nalur.1 0 Homicide
<br />
<br />o AccldenlO P.ndlng Invesllgatlon
<br />
<br />o Suicide 0 Could nol be delermlnad
<br />
<br />21 b, IF TRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />Q Passenger
<br />
<br />o Pedestrian
<br />
<br />o Other (Spacify)
<br />
<br />21c. WAS AN AUTOPSY PERFORM!::D?
<br />
<br />DYES
<br />
<br />X>>w
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH'
<br />
<br />o Y!::S
<br />
<br />o NO
<br />
<br />DYES 0 NO
<br />
<br />
<br />22a. DATE OF INJURY (Mo., Day. y,)
<br />
<br />2>.b. TIM!:: OF INJURY 22c. ?LACE'OF II>IJURY'At home, farm, s1reel, factory, olllea buifdinQ, construction site, etc. (Sp.clfy)
<br />m
<br />
<br />22d. INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23.. DATE OF DEATH (Mo" Day, Yr.)
<br />February 6, 2005
<br />
<br />24a. DATE SIGNED (Mo" D.y, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />23c. TIME OF DEATH
<br />1:05 P. m
<br />
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<br />
<br />24c. PRONOUNCI::D DEAD (Mo" DAY, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />248. On the basis of examinatIon and/or investigation, in my opinion death occurred at
<br />the time, d.le and place and dua to the cAuse(s) slaled. (Signalllre and Title) "
<br />
<br />26.. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />DYES 0 NO U PROBABLY XXUNKNOWN 0 YES ~O Not AppliCAble H.~~als N()..U YES U NO
<br />-'ii7:'NAiXf,TiTLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CC)RONEFl'S PHYSiCIAN OR COUNTY ATTORNEY) (Type orPrlnij
<br />M.A. Tc:mpkins, M.D., Grand Island Veterans Hane, Grarrl Island, NE 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />
<br />FEB 1 4 2005
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