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<br />~
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTtI:MiDHmdANSERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGIrn..-t:..pECCiRd'ONFliE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST~S'lIj;s',!SECTIO!'l,'JNtiicH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.Pi:/'-= ...Kt....-~--.--.=-_.~.=-
<br />
<br />
<br />D;~ELO~ '~S~~~~E 20060636 9 ~TAN~~R'
<br />A~SISTANtS[AJ~I!EGISr1iAR
<br />.....LINCOLN, NEBRASKA HEAf..TH MlP~CES"---~
<br />'..::~ ,~..:.~,,7 -.. =::g:;:::
<br />.. ---",:,,-_._~,,-,.-
<br />'. :''.-:::':~',-~''-=''-,-..'.''''
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPOR 27 335
<br />CERTIFICATE OF DEATH' 6 .. {.._~
<br />
<br />.""
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />DECEDENT'S-NAME (Flrsl,
<br />Eleanor
<br />
<br />Middle, La't,
<br />Jeanette Lindly
<br />
<br />Suffix)
<br />
<br />2.SEX
<br />Female
<br />
<br />3. DATE OF DEATH IMo.. Day, Yr.)
<br />June 28,2006
<br />
<br />Nebraska
<br />
<br />5a. AGE-Last Birthday 5b. UNDER 1 YEAR
<br />IYrs.) MOS. DAYS
<br />64
<br />
<br />5e. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />
<br />February 20,194
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />505-54-7497
<br />
<br />6e. PLACE OF DEATH
<br />l:iQ.SElI&: []Clnpetlenl
<br />
<br />QIt!EB: 0 Nursing Home/LTC 0 Hospice Faclllly
<br />
<br />8b. FACILITY-NAME (It nol in,lilutlon, give ,treel and number)
<br />st. Francis Medical Center
<br />
<br />o ER/Outpellent
<br />
<br />(J Deced@nt's Home
<br />
<br />_~~:~:rl
<br />
<br />Ave
<br />
<br />o 00i\ U Other (Specily)
<br />
<br />. ....~~~yrDEATH
<br />=rTG;T~~d I s~and .....
<br />.~O 9~~~OO1
<br />
<br />lOb. NAME OF SPOUSE IFirst, Middle, Last, Suffix) If wifo, give maiden name.
<br />Roger Lindly
<br />
<br />9g. INSIDE CITY LIMITS
<br />IX YES 0 NO
<br />
<br />8C-a~ iif}i~N 3: ~":tT~AnCi"de Zi~~~ 0 3
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH ~ Married 0 Never Married
<br />
<br />o Married, bul separated 0 Widowed 0 Divorced 0 Unknown
<br />
<br />11. FATHER'S-NAME (First,
<br />Gary
<br />
<br />Middle,
<br />
<br />Last, Sulllx)
<br />Trotter
<br />
<br />"]'2. MOTHER;S.~AME IFlrst,
<br />Mary
<br />., oW
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />Friche
<br />
<br />o EntombmMI
<br />
<br />14a.INFORMANT-NAME
<br />Roger Lindly
<br />16aE : GA!)~& ;--nm
<br />
<br />16d CEMETERY, CREMATORY OR OTHER LOC7;;/; CITY / TOWN
<br />Grand Island City Cemetery Grand
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dales 01 service if yes.
<br />IYes, no, or unk.) No
<br />
<br />o Donation
<br />
<br />16c. DATE (Mo., Day, Yr. )
<br />
<br />'_l,t ty I, 21Jf)b
<br />STATE
<br />Island Nebraska
<br />
<br />U Other (Specify)
<br />
<br />PART l. Enter the chAIn 01 events--diseases, injuries, or compllcationsnthat directly caused the death. DO NOT enter termInal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology, DO NOT ABBREVIATE. Enter only one cause on a line. Add addllionallines If necessary.
<br />
<br />
<br />.....-- ..--.-.--
<br />17a1F\lNERAL HD.ME ~^ME AND MAILING ADDaESS.JSlreet, Cily (l(\llwJl" J/.taleL
<br />A 1 Faltns Funeral Home .l~L~ ::;.
<br />
<br />l
<br />
<br />tMMEDIA TE CAUSE (Final
<br />disease or conditIon resulting
<br />Indealh) .
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />~_~~4.
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />o (/ O'?/o- . .6-. c....,
<br />
<br />I
<br />I
<br />
<br />I onsello dealh
<br />I
<br />I......... ?
<br />I J w-A6\.n
<br />I onsetfo death
<br />I
<br />I
<br />I
<br />I onsel to death
<br />I
<br />I
<br />I
<br />
<br />Sequentially IIsl conditions, If
<br />any, Icadlng to the cause listed
<br />onllnee.
<br />Enler tho UNDERLYING CAUSE
<br />(dlsea.e or Injury lhotlnillated
<br />theevenl. resulllng In death)
<br />LAST
<br />
<br />(b)
<br />
<br />DUE TO, OR AS A CONS~QUENCE OF:
<br />
<br />Ie)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />Id)
<br />
<br />21a-",M1NNER OF DEATH
<br />Not pregnant wHhln past year .,)'lNatural 0 Homicide
<br />o Pregnanl at time 01 death lJ AccidentD Pending Investigation
<br />[J Pedestrian
<br />o Nol pregna"l, bul pregnant willi in 42 days 01 death U Suicide 0 Could nol be determined 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o NOI pregnanl, bul pregnant 43 days 10 1 year belore death 0 Other (Specify) COMPLETE CAUSE OF DEATH'
<br />~_un~nownlfPrOgn"nlwithlnlhepasty~- ~_~ ~_ _ ___ __~ ------:-_-____=_=_ _-=----____ "_-':~- ~O
<br />22.. DATE OF INJURY. (Mo., Day, y,.)]:::ME OF'INJUR: I 22c. -PLAC~-OF INJURHI home, farm, slreel, factory, -oif,Ce bUlldln~ "onslruetlO" Slt;"~tc. (Specify) __ ___
<br />
<br />--22d INJURY AT WaRP -] 220 OESCRIBE HOW INJlJ-RY OCCURRED
<br />DYES 0 NO
<br />____ _._n ----
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO. CITYITOWN STATE
<br />
<br />21 b.IFTRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />o Pa,sengor
<br />
<br />=rr".. 19. WAS. .M. ..EDICAL EXAMI.NER .
<br />OR CORONER CONTACTED?
<br />DYES 0 NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Condition, ccntribuling 10 Ihe death but nol losulllng In the underlying cause given in PART I.
<br />
<br />DYES
<br />
<br />~NO
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mc., Day, Yr.)
<br />
<br />24a. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />24b.TIME OF DEATH
<br />
<br />m
<br />
<br />,.~ ~
<br />J:I~a:
<br />H~
<br />0. a.. irJ.: ~
<br />E.'" ~ z
<br />0'" 0
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<br />,8Z=>
<br />~~8
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<br />
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<br />
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<br />,g-~
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<br />ii~
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<br />0"'0
<br />" ~
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<br />.>!!
<br /><l
<br />
<br />
<br />24c. PRONOUNCED DEAD (Mo.. Day, Yr.)
<br />
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e, On the basIs 01 examination and/or investigation, in my opinion death occurred at
<br />Ihe lime, dale and place and duelo the causels) staled. (Signalure and Tille)"
<br />
<br />26.DIDTOBA 0 USE CONTRIBUTETOTHE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />
<br />
<br />n-1~~:i3~~~~6TI~~~~~lEd~i~~~~lP~~~~~~CtN.OR ~~~~RNr~(r~~dl: N ebr ::::able if~6~ I~~ 3 0 YES LJ~_
<br />
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />:JUl
<br />
<br />Ii 2006
<br />
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