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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND f!UMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL BECORCiON"'FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIg/(tS.SiU:tION,WHICH IS
<br />
<br />
<br />::M:A;Y:::~9:2PNoOCoSE6rroRY FOR VITAL RECORDS. ~~E;'
<br />2 0 0 6 0 6 5 5 7 A$.IST~NT'sfAiE-REGI$TRAR
<br />LINCOLN, NEBRASKA HEAI.;TH ANO--tlLJ.MJ!N SERVICES
<br />
<br />.-... . .
<br />STATE OF NEBRASK. A - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANC~ANb sUPPOI}\ 6 2. 50,6. .._..,9_' !
<br />._.u___I:ERTIFICATE OF DEATH __._~_
<br />
<br />1. DECEDENTS-NAME (First. Middle, Lasl, Suffix) 2, SEX 3. DATE OF DEATH (Mo" Day, Yr.)
<br />James Carl Creech Male April 28,200,?_
<br />
<br />
<br />5a. AGE.Lasl Birthday
<br />
<br />5b, UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />5c, UNDER 1 DAY
<br />HOURS I MINS
<br />
<br />B. DATE OF BIRTH (Mo" Day, Yr.)
<br />February 12, 1924
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />(Yrs.)
<br />
<br />82
<br />
<br />Moravia, Iowa
<br />
<br />Ba. PLACE OF DEATH
<br />!:IQ.5EJIAL 0 Inpalienl
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />508-30-3018
<br />
<br />oTl:lm it+Iorsing Home/LTC 0 Hospice Facllily
<br />
<br />8b. FACILITY-NAME (If nol inslilution. give streel end number)
<br />
<br />U En/Outp.tient
<br />
<br />o Decedentls Home
<br />
<br />Bickford Cottage
<br />
<br />o 0C1\ XI Olher(Sp.clfy) ARS' t .hiving
<br />l ad, COUNTY OF D-.~T;ll
<br />
<br />Sc, CITY OR TOWN OF DEATH (Includ. Zip Code)
<br />Grand Island
<br />
<br />68801
<br />t' COUNTY
<br />Hall
<br />
<br />9g.INSIDE CITY LIMITS
<br />W YES 0 NO
<br />
<br />gC. CITY OR TOWN
<br />Grand Island
<br />
<br />.----tA~T, NO 9fZI~~~~1
<br />
<br />lOb, NAME OF SPOUSE (Flrsl, Mlddl., L.sl, Suffi,) If wife, glv. maiden name.
<br />
<br />Nebraska
<br />9d, STREET AND NUMBER
<br />
<br />3285 Woodri~g~ Blvd.
<br />lOa. MARITAL STATUS AT TIME OF DEATH 0 Married 0 N.var Married
<br />
<br />o Married, but separated cX.Wldowed U Divorced 0 Unknown
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S-NAME (Flrsl,
<br />Ger.trude
<br />
<br />Middle, Maiden Surname)
<br />A. Glasgow
<br />
<br />11, FATHER'S.NAME (Firsl, Middle, Last,
<br />James J. Creech
<br />13. EVER IN U~S: ARME. D ~~RCES? Give dates OI..rVIC..".~.. s.'. 11';'~I~FORMANT'NAME -.....
<br />(Yes, no, orunk)__X_€Js: 10/27/1941 9 U 1{1945 Judy Creec:b..
<br />15, METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE
<br />~Burial o Donalion . ..' ~'-4f{~
<br />o Cremation 0 Enlombm.nt 16d. CEMETERY, CREMATORY OR ~ LOCATION
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />IJ~ugh~er
<br />16c, DATE (Mo.. Day, Yr.)
<br />May 9, 2006
<br />
<br />16b. LICENSE NO,
<br />~5z.r
<br />
<br />CITY !TOWN
<br />
<br />STATE
<br />
<br />o R.moval 0 Oll1er (Specify)
<br />
<br />Grand Island, NE
<br />
<br />Westlawn Memorial Park Cemetery
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, Cily or Town. SI.le)
<br />Apfel Funeral Horne, 1123 West Second,
<br />
<br />
<br />PART I. Enter the r.haln of BvenlsudiSEl8ses, injuries, or compllcatlona--that directly causE!.d the death. DO NOT enter terminal events such as cardiac a.rrest,
<br />respiralory arrest, or ventricular flbrlll.llon wllhout showing the etiology. DO NOT ABBREVIATE, Enter only one cause on . line, Add additional lines if n.c.ss.ry.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />onsello death
<br />
<br />IMMEDIATEgAU E:
<br />
<br />(a) ..(.."'-"~~
<br />--DUE TO, 0 AS A CONSEQUENCE OF: - - ~
<br />
<br />..- i) .
<br />t ___~-----1)~~
<br />1 ........ - ...---
<br />
<br />~..fi---O::1'''''-;;:?
<br />on, t dealh
<br />
<br />IMMEDIATE CAUSE (Final
<br />di..... or condition r.sultlng
<br />In death)
<br />
<br />(b)
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />Sequentially list conditions, If
<br />any, leading to the couse listed
<br />on linea.
<br />Enlo,tha UNDERLYING CAUSE
<br />(dls.a.e or tnJurylhatlnlllated
<br />the events resulting In death)
<br />LASr
<br />
<br />on'ello deeth
<br />
<br />(c)
<br />--..-. .-
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsel to death
<br />
<br />(d)
<br />
<br />19, WAS MEDICAL EXAMIN.R
<br />OR CORONER CONTACTED?
<br />o YES 0 NO
<br />
<br />20. IF FEMALE: 21..~ER OF DEATH 21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Nol pregnant wltl1ln pa,1 year ~Iural U Homicide 0 Driver/Operalor 0 YES
<br />o P,egnent.llime of dealh 0 AccldentO Pending Invesligallon 0 P."enger ~O
<br />
<br />o Nol pregnanl, bul pregnenl within 12 days at death 0 Suicide 0 Could nol be determln.d 0 Ped.strlan 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Not pregnanl, but pregnanl43 day' 10 1 year before daath 0 Olh.r (Specify) COMPLETE CAUSE OF DEATH?
<br />
<br />o Unknown II pregnant within tho past ya.. 0 YES 0 NO
<br />2"2;- DATE'OF-INJURY (MO, Day, Yr ) [TIME OF INJUR: i 22c. PLACE OF INJURY-At home, farm, ",eel,laclory, ollie. building, cnnstruction sile, etc, (Specily)
<br />
<br />22d.INJURY AT WORK? ----[22;;[)ESCRIBE HOW INJURY-OCCURRED . .. . .... -.-
<br />o YES 0 NO
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT, NO. CITYrrOWN STATE ZIP CODE
<br />
<br />18, PART II. OTHER SIGNIFICANT CONDITlONS-Condlllon' conlribullng to Ihe dealh bul nol ,e.ulllng In Iho underlying cause glv.n In PART I.
<br />
<br />
<br />24a. DATE SIGNED (Mo" Dey, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />z>
<br />!'~~
<br />_a:
<br />'C1Jl~
<br />-Ii>
<br />c.l<~
<br />e~>z
<br />8ffi!z:0
<br />..z::>
<br />.coo
<br />,s!a:0
<br />o ~
<br />00
<br />
<br />m
<br />
<br />240, PRONOUNCED DEAD (Mo" Day, Yr,) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e, On thg basis of examlnallan and/or investigation, in my opInIon dealh occurred a.t
<br />111. lime, date and place and due 10 th. cau'e(s) slat ad. (Signalure and Title) -.-
<br />
<br />25, DID TOBACCO USE
<br />
<br />2Sa. HAS ORGAN OR TISSUE DONATION seEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />NOI A~e!lcable II 26a Is NO 0 YES ~O__
<br />/~.\'
<br />
<br />----.9~_~..!:!~_ 0 PROBABLY UNKNOWN U _YE~.____n ~O.__
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (PH'fSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Gordon J. Hrnicek M.D. 729 N. Custer, Grand Island, NE
<br />
<br />68803
<br />
<br />28a, REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />MAY 8 2006
<br />
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