|
<br />.~
<br />
<br />-,".. ~
<br />
<br />STATE OF NEBRASKA
<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 STATISTICS .s~Cr"qN, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~., "-.:.....,::.. .-.-"l~. i/~.-..'c,-. o~._.'_
<br />
<br />DATE OF ISSUANCE _ ".Kfic:'fNllJf;____
<br />APR 0 6 ?OOh f/-c/ TANLEYS:' (:OOPE/i
<br />
<br />LINCOLN, NEBRASKA 2 0 0 6 0 5 6 61 r/~~~~:~r;;;s:c~~::~;~
<br />
<br />1. DECEDENT'S-NAME
<br />Johnny
<br />
<br />STATE OF NEB.. .RA. SK.A. - DEPARTMENT OF HE.A.. LTH A. NO HUMANSERVICES'FINANCE A. NO. SVPPORT O' 6' 2.35' 2'., 8'.
<br />. _. CERTIF~t::~T~ OF DEATH :.__ __ _
<br />
<br />(First, Middle, Last, Suffix) 2. SEX 3, DATE OF DEATH (Mo., Day, Yr.)
<br />(NMI) Taylor Male March 21, 2006
<br />
<br />\
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE.Last Birthday 5b, UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo" Dey, Yr,)
<br />
<br />(Yrs.) MOS, DAYS HOURS MINS.
<br />72 November 1, 1933
<br />
<br />Bethany, ~ssouri
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />505-52-1580
<br />
<br />8.. PLACE OF DEATH
<br />I:illBPITA.L:
<br />
<br />o Inpatient
<br />
<br />QIl:IEB: 0 Nursing Home/LTC 0 HosplcD Facility
<br />
<br />Bb. FACILITY-NAME (ff not instllutlon, give slreet and number)
<br />
<br />o ER/OUlpallent
<br />
<br />.Decedent's Home
<br />
<br />1124 W 11th St.
<br />
<br />0=
<br />
<br />U Other (Speclly)
<br />
<br />Be, CITY OR TOWN OF DEATH (Include lip Code)
<br />Grand Island 68803
<br />
<br />9a.::~~:~;..,___ -"Tb:COUN~~~_!..._
<br />
<br />9d. STREET AND NUMBER
<br />1124 W 11th St.
<br />
<br />8d. COUNTY OF DEATH
<br />
<br />Hall
<br />
<br />9c, CITY OR TOWN
<br />
<br />o Never Msrrled
<br />
<br />Grand Island
<br />
<br />:EAPT ~~__ 9~~~C;~E
<br />
<br />10b. NAME OF SPOUSE (First, Middle, Last, Sutflx) If wile, give maiden nsme.
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />)!l YES 0 NO
<br />
<br />U Divorced 0 Unknown
<br />
<br />Joyce A. Stoltenberg
<br />
<br />Middlo,
<br />Taylor
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S-NAME (First,
<br />Anna (NMI) Lowe
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />
<br />13, EVER IN U,S, ARMED FORCES? Givo datos ol.orvlcoll yes. 14e, INFORMANT-NAME
<br />(Yes, no, orunk,) 02/10/1953-09/30/1973 Joyce (NMI) Taylor
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />16s, EMBALMER-SIGNATURE
<br />(Not Embalmed)
<br />
<br />1 6d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />1 6b. LICENSE NO,
<br />
<br />16c. DATE (Mo" Day, Yr, )
<br />March 22, 2006
<br />
<br />STATE
<br />
<br />o Burial
<br />
<br />.0 Do"allcn
<br />
<br />~ Cremalion 0 Enlombmenl
<br />
<br />CITY I TOWN
<br />
<br />URemoval DOther(Specily) Central Nebraska Cremation Service, Gibbon, Nebraska
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Slale)
<br />Kleine Funeral Home, 3213 W North Front
<br />
<br />PART I. Ent.r tho chain of events..disoasos, Inju'los, or compllcalions--that directly caused the death, DO NOT antor terminal evonlS such os cardlsc arrest,
<br />reopl,atory s"est, Or ventricular fibrillation without 'howing the ellology, DO NOT ABBREVIATE. Entor only one cau,. on a lino. Add additional IIno. II necossary,
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />I
<br />I
<br />I
<br />I
<br />
<br />. ._.__1
<br />I
<br />
<br />onsello dosth
<br />
<br />onset 10 dsath
<br />
<br />IMMEDIATE CAUSE (Finol
<br />disease or condhlon resulting
<br />In death)
<br />
<br />(a) Ca rd i 0- pu 1 mOl1.(\rY~9I!,_es t
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />5 minutes
<br />
<br />Sequentially lIa' conditions, If (b) he art d;j, sea s e
<br />any, leedlng to the COUSe listed DUE TO,-OR AS-A- CONSEQUENCE OF:
<br />on line a.
<br />Enter lhe UNDERLYING CAUSE
<br />(dls.as. or Injury Ihot Initiated (c)
<br />the Svonta reSUlting In death)
<br />LAST
<br />
<br />I
<br />
<br />: unknown
<br />
<br />I onsotto death
<br />I
<br />I
<br />
<br />..J. ,__
<br />I onselto death
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(d)
<br />
<br />18, PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contrlbullng 10 the death but not rosultlng In tho undorlylng cause glvon In PART I.
<br />
<br />19,WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />(2i YES 0 NO
<br />
<br />20. IF FEMALE;
<br />o Not prognanl within past year
<br />o Pregnsnl at tlmo 01 doath
<br />o Not prognont, but pregnsnl within 42 doys 01 death
<br />o Not prognanl, but pregnsnl43 days to 1 yoar beloro doath
<br />o UnkMwn If pregnant within the past year
<br />
<br />21a, MANNER OF DEATH
<br />)([ll Natural 0 Homicide
<br />
<br />21b.IFTRANSPORTATION INJURY 21c, WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />U Passenger
<br />
<br />Qg NO
<br />
<br />DYES
<br />
<br />o AccldentD Pending Invo'tigation
<br />o Sulcldo 0 Could not be dotermlned
<br />
<br />o Pedestria.n
<br />o Other (Specify)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES UNO
<br />
<br />~" -~.,- .,,~"--
<br />22a, DATE OF INJURY (Mo" Day, Yr,) 22b. TIME OF INJUR: I 22C:.PLACE OF INJURY-AI home, larm, street, factory, ollice building, construction sito, etc. (Specily)
<br />
<br />
<br />22d.INJURY AT WORK? 220. DESCRIBE HOW INJURY OCCURRED
<br />
<br />
<br />DYES U NO
<br />
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT NO.
<br />
<br />CITY/TOWN
<br />
<br />STPJE
<br />
<br />ZIP CODE
<br />
<br />?o3a, DATE OF DEATH (Mo., Day, Yr,)
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />March 23, 2006
<br />
<br />24b. TIME OF DEAT';.Mi dn ig h t
<br />12:0U arrr
<br />
<br />,.,~~
<br />J:l~a:
<br />ilUlo
<br />]i~1=
<br />c.D. 41: ~
<br />1i'.V> ~ is
<br />8ffiz
<br />"z::>
<br />.coo
<br />~~u
<br />O~
<br /><'>0
<br />
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />
<br />the limo, dato and pisco snd due to the causel~) sl1tlljJ. (Sillnature!l!'d Title) T
<br />/Ma I l,-OUn l.y
<br />
<br />/ Attorne
<br />
<br />AS CONSENT GRANTED?
<br />
<br />z
<br />~S
<br />'Ol,!
<br />U~
<br />Q.:J:~
<br />e"-z
<br />0"'0
<br />'" ~
<br />H
<br />t2!
<br /><l
<br />
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />23c, TIME OF DEATH
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />March 21 2006
<br />
<br />24d. TIME PRONOUNCED DEAD
<br />7: 14 am
<br />
<br />m
<br />
<br />23d, To the best 01 my knowledge, doath occurro~ at the lime, dale and plsce
<br />and due 10 the causo(s) steted. (Signature and Titlo) T
<br />
<br />25, DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />
<br />,
<br />
<br />DYES 0 NO 0 PROBABLY .liJ UNKNOWN 0 YES ~ NO
<br />_~,. '_"'..'~_._".,'.'" ~., .". _n__.,., ." '.. __ ,.
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typo or Print)
<br />Mark J. Y
<br />
<br />1
<br />
<br />Not Applicablo 1126a Is NO 0 YES >tJ NO
<br />
<br />
<br />APR
<br />
<br />3 2006
<br />
|