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<br />STATE OF NEBRASKA
<br />
<br />MAR 0 ~ 200F
<br />LINCOLN, NEBRASKA
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMANSEflVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL.1rECURlJ.DNf/LE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL.5TA7}!f('[C$;Sl!C1!I.ON:WHICH IS
<br />
<br />:::;::~~:::::~TORY FOR VITAL RECORDS. .... ff? ~-:- ~'J-~~
<br />~rA'tlUr~. ~R
<br />~~~TANT STATERE~t$TF!AR
<br />HE~LTf'I--!4ND HUMAN_SERViCES
<br />
<br />200606492
<br />
<br />'. ~- ~,~\.:,. ...
<br />
<br />~
<br />
<br />--.
<br />.-.--- -
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT 0 6
<br />_______ ________ CERTIFICATE OF DEATH
<br />
<br />21931
<br />
<br />DECEDENT'S-NAME (First,
<br />Kenneth
<br />
<br />Middle,
<br />Earl
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />2.SEX
<br />Male
<br />
<br />3. DATE OF DEATH (Mo" Day, Yr.)
<br />Fe b. 17 2006
<br />
<br />Staton
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sac City! Iowa
<br />7. SOCIAL SECURITY NUMBER
<br />48S~28-490S
<br />
<br />Sa. AGE.Last Blrlhday 5b. UNDER 1 YEAR
<br />
<br />(Yrs) 6 9____ ~.~_S~~L~AYS
<br />
<br />Ba. PLACE OF DEATH
<br />
<br />5c. UNDER 1 DAY 6. DATE OF SIRTH (Mo" Day, Yr.)
<br />HOURS MINS.
<br />
<br />May 16, 1936
<br />
<br />I:IJ2SJ:lJAL
<br />
<br />o Inpollenl
<br />
<br />QlliEB' 0 Nurolng Hom./LTC 0 Hooplce Faclllly
<br />
<br />i1!i Decedent's Hom.
<br />
<br />8b. FACILITY-NAME (If not lnatltullon, give street and number)
<br />
<br />U ER/Oulpallent
<br />
<br />_ka
<br />9d. STREET AND NUMBER
<br />
<br />
<br />68801
<br />19b. COUNTY
<br />
<br />Hall
<br />
<br />o OCI\ U Other (Bp.clly)
<br />
<br />~~Y~FDEATH
<br />L ~T~O~:~N I Lall ~
<br />!~ NO 9f ZIP CODE
<br />L_ 68801
<br />lOb. NAME OF SPOUSE (First, Middle, Last, Suffix)ff wife, give maiden name.
<br />
<br />9g. INSIDE CITY LIMITS
<br />00 YES 0 NO
<br />
<br />----.1_Q_L_Q_C>_llt_h PIe a SJ_ ant vie w D r i v e
<br />
<br />BC. CITY OR TOWN OF DEATH (Includ. Zip Code)
<br />
<br />r nd Island
<br />9.. RESIDENCE.STATE
<br />
<br />704 South Pleasant view Dr
<br />lO;MmrAL STATUSATi-IME OF DEATH - 'XYM~~;;;d 0 Never M;;~e~'
<br />
<br />
<br />o Married, butseparatad 0 Widowed 'U Divorced 0 Unknown (McCrea)
<br />LouRae Staton
<br />FATHER'S-NAME-(FlrSI, -Middle, - ---Last,- Suffix) [12MO:;:-H-EFl'S-NAME (First,
<br />Dr e w ______ J3 ~ at 0 n__ ___ __ __-----.H.a z e_l__.
<br />13 EVER IN U S ARMED FORCES? G,V. dates of service If yes T14a INFORMANT-NAME
<br />....IYe.,~0,~r_~n_kLye~~6_~~ 196~_ _ ILouR~~_ta ton
<br />15: METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE 16b. LICENSE NO.
<br />
<br />Middle, CartelMald.n Surname)
<br />kCr~....
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />16c. DATE (Mo" Day, Yr. )
<br />
<br />o Burial
<br />
<br />o DonaHon
<br />
<br />Not Embalmed
<br />1 6d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />
<br />t-- ?OOf.
<br />STATE
<br />
<br />00 Crsmatlon U Enlombmenl
<br />o Removal 0 Other (Specify)
<br />
<br />CITY /TOWN
<br />
<br />Central Nebraska Cremation Service
<br />
<br />Gibbon, Nebraska
<br />
<br />"--'--'.'"
<br />17a. FUNERAL HOME NAME AND MAiliNG ADDRESS IStre.t, Clly orTown, Stale)
<br />
<br />NE
<br />
<br />...---...--.-
<br />17b. Zip Code
<br />68801
<br />
<br />PART l. Enter the chain of evenlgudiseases, injuries, or complications--that directly caused the death. DO NOT enler terminal events such as cardiac arrest,
<br />respiratory arras!, or ventrIcular Iibrlllallon without showing Ihe ellology, DO NOT ABBREVIATE, EnteT only one causa on ~ line. Add additional lines if necessary.
<br />
<br />IMMEDIAT~ QAUSE: r ," . <..~:L '''..
<br />
<br />::::::::::::. :m(:1JM~~ilY41"v~,:,"72f'!J~
<br />
<br />Indoath) I""., I) ..
<br />
<br />Soquonllally list condlllons, If (b). L~'^. ([,C..{,.IA../-U.. f;_ il.:f.A"t..-a{.'. _"
<br />any, leodlng to the caUSe listed DUE TO OR AS A CONSEOUENCE OF'
<br />~~~ ' ..
<br />"
<br />Enter the UNDERLYING CAUSE
<br />(dls.... or Injury that Inltlat.d (c)
<br />theevonts resulting In death) ....... DUE TO, OR AS A CONSEQUENCE OF:
<br />lASr
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />Onset to death
<br />
<br />on'. et to death , ~~)
<br />
<br />a ftt/J.tl/k,;)
<br />
<br />(d)
<br />
<br />I
<br />I
<br />I
<br />I
<br />I on..tto d.ath
<br />I
<br />I
<br />
<br />J___ .___ ._ .
<br />I onset to death
<br />I
<br />I
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Condlllons conlrlbullng to tho d..tll bUlnot r..ultlng In tho und.rlylng cau.. glvon In PART I.
<br />
<br />_(~_~!!lLttP~;L({i/~lt'- l!(>1I!-ttAL.C-
<br />
<br />20. IF FEMALE: 21a. MANNER OF DEATH
<br />t.J'Natural U Homicide
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />o YES ~O
<br />
<br />o NOI pregnant wllhln past y.ar
<br />
<br />21b.IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator ./"
<br />U YES I). NO
<br />
<br />o Pa,senger
<br />Q Ped.strian
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />o Pregnanl at lime of death
<br />
<br />o AccldentO Pending Investigation
<br />
<br />U Not pregnanl, but pregnant wllhln 42 days 01 death
<br />o Nol pregnant, bUI pregnanl43 days 10 1 year betors death
<br />o Unknown It pr.gnant within the past y..r
<br />- 22;-DATEOFINJURY-(M~~Y:Y~) . ..--'tb_ T~M_E_~FI~::_~n
<br />22d.INJURY AT WORK? n.. DESCRIBE HOW INJURY OCCURRED
<br />
<br />o Suicide 0 Could not be determined
<br />
<br />o Oth.r (Sp.clly)
<br />
<br />o YES
<br />
<br />o NO
<br />
<br />22c. PLACE OF INJURY-At home, larm, stre.t, laClory, otflc. building, construction sile, etc. (Specify)
<br />
<br />o YES 0 NO
<br />
<br />221. LOCATION OF INJURY - STREET & NUM6ER, APT. NO.
<br />
<br />CITY/TOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />
<br />23a. DATE OF DEATH (MO., Day, Yr.)
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />Ee hruer y_...lL_2JlO
<br />23b. DATE ~!.Gl:I D (Mo., Day, Yr)
<br />ebua 2 206m
<br />23d. To the beSl JJ'1Y knowledge, death ooqlmed al the time, date and place
<br />.td du~,1 h.causels) ,Iat.d. (Sl9flllUre and Tille) "I' _
<br />
<br />\.. / a.l(.,/.{(,( .~..----
<br />
<br />25. DIDT06AqCOYSE CONTRIBUTE TO HIE DEATH? /' 26a. HAS ORGAN OR TISSUE DON,~TION BEEN CONSIDERED?
<br />
<br />o YESiO NO ~ROBABLY 0 UNKNOWN 0 YES liJ1.io
<br />... 27.NAME:trr[~-AND ,iDDfiESSOFCERTIFiEFi-iPHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEyj-iTyii.orP;irliY~--
<br />Dr John A Wa oner MD ha Grand Islano,NE
<br />
<br />
<br />...~i:i
<br />",Qz
<br />al",gj
<br />liH:
<br />"6.a..4(~
<br />g..'" t~
<br />...ffiz
<br />~..:>
<br />"'00
<br />~a:U
<br />o~
<br />uo
<br />
<br />m
<br />
<br />240. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />248. On the basIs of examlnallon and/or Investigation, in my opinion death occurred at
<br />tho tlm., date and plac. and due to the cause(s) slaled. (SignalUre .nd Till.) "I'
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />Not Appllcabl. if 26a Is NO 0 YES i:!(NO
<br />
<br />68803
<br />
<br />28a. RE:GISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />FEB 2 '1 2006
<br />
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