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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANQJiYMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINALiiEt;lilftiONfILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAJjS'tX;S:'$fqfijDrj;'.Wt-tICH IS
<br />
<br />:::;::~~:::::;TORY FOR VITAL RECORDS. 11~{~:A'~~
<br />APR 2 0 2006 ""~~fiiTAJilEr~. COOPER
<br />ASSISTANT STATE REIl1STfiAR
<br />LINCOLN, NEBRASKA 200606621 HE.4.LTH-ANt;JHI/MAf'JSER'l./CES
<br />
<br />~
<br />
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPOR"O 6'.
<br />_.____ CERTI..F.ICATE OF DEATH
<br />
<br />24326
<br />
<br />1. DECEDENT'S-NAME (FirS!,
<br />Kay
<br />
<br />Middle,
<br />Ann
<br />
<br />Lasl,
<br />Janzen
<br />
<br />Suffix)
<br />
<br />2. SEX
<br />Fem.ale
<br />
<br />3. DATE OF DEATH (Mo" Day, Yr.)
<br />April 9, 2006
<br />
<br />4. CITY AND STATE OR TERRiTORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE.Last Birthday 5b. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />54
<br />
<br />5c. UNDER 1 DAY
<br />. _.~ ".._,~,.
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Me.. Day, Yr.1
<br />
<br />Grand Island, Nebraska
<br />
<br />July 20, 1951
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />506-72-9323
<br />
<br />ea. PLACE OF DEATH
<br />~: Q Inpatient
<br />
<br />Qlliffi: IX Nursing Home/LTC Q Hosplca Fecillly
<br />
<br />eb. FACILITY. NAME (If nol In.titullon, glva olraal and number)
<br />
<br />Q ER/Oulpallant
<br />
<br />o Decedenfs Home
<br />
<br />Francis Skilled Care Nursing
<br />
<br />OIXl'\
<br />
<br />o Olher (Speclfyl .
<br />
<br />8c. CITY OR TOWN OF DEATH (Includo Zip Coda)
<br />Grand Island, 68803
<br />
<br />19b. COUNTY
<br />Hall
<br />
<br />ed. COUNTY OF DEATH
<br />Hall
<br />
<br />":'.'.'g~;:~;;W~.~land
<br />
<br />90. APT. NO Sf. ZIP CODE
<br />68803
<br />
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />_ YES 0 NO
<br />
<br />9d. STREET AND NUMBER
<br />2207 Del Mar
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH lXMarried Q Navar Marrlad 1 Db. NAME OF SPOUSE (First, Mlddla, Las I, Sulllx) If wlfa, give m.ldan nama.
<br />
<br />o Marrlad, buls.parated 0 Widowad 0 Divorcad U Unknown
<br />
<br />Burl
<br />
<br />Janzen
<br />
<br />11. FATHER'S.NAME (Flrsl,
<br />NOrJllan
<br />
<br />Middle,
<br />H.
<br />
<br />Lasl,
<br />McKeag
<br />
<br />sumx)
<br />
<br />12. MOTHER'S.NAME (Firsl,
<br />Dorothy
<br />
<br />Middle,
<br />J.
<br />
<br />Malden Surneme)
<br />Brittin
<br />
<br />13. EVER IN U.S. ARMED FORCES? Glva dales olse,vice If yes. 14e.INFORMANT.NAME
<br />(YaS,nO,orunk.) No -c> Burl Janzen
<br />15. METHOD OF DISPOSITION
<br />_Bu,lal 0 Donallon ~
<br />
<br />'-
<br />
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />
<br />16b. LICENSE NO.
<br />1092
<br />
<br />Q Cramallon 0 Entombmenl
<br />
<br />CITY /TOWN
<br />
<br />160. DATE (Mo.. Day, Yr.)
<br />Apr 13, 2006
<br />
<br />STATE
<br />
<br />IJRamov.1 o Othe,(Speclly) Westlawn Memorial Park Cemeterr.,.
<br />
<br />Grand Island
<br />
<br />NE
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<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Str.et, City or Town, Stoia)
<br />Curran Funeral Chapel 3005 South Locust
<br />
<br />
<br />PART I. Enter the chair.LQ.Le.Y.e.D.lA--diseeses, Injuries I or complications-that directly caused the death. DO NOT en1artermlnal evenls such as cardiac a.rrest,
<br />raspiratory a"es" or ventricular fibrilla lion wlthoUI .howlng tho etiology. DO NOT ABBREVIATE. Enter only one cause on allno. Add additional line. if necessary.
<br />
<br />tMMEDIA TE CAUSE (Ftnal
<br />dl9S8se or conditlon resUlting
<br />in death)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />(e) '6~ 6"
<br />
<br />DUE TO, OR AS A CONSEQU~ OF:
<br />
<br />~~A~
<br />
<br />I
<br />I
<br />I
<br />I onSet 10 d7
<br />
<br />I/..:.l/O f-"';;:">
<br />
<br />onsal to death
<br />
<br />Sequentially lIal condltiona, If (b)
<br />any,l.adlnglothe""uaell.l.d Oli-~TO, OR ASA CONSEQUENCEOF:----
<br />on line e.
<br />Enter !he UNDERLYING CAUS~
<br />(dl..... or Injury that Initiated (c)
<br />tho events ..aulting In doath) . DUETO, OR AS A CONSEQUENCE OF:
<br />LJ\SI'
<br />
<br />I
<br />,
<br />I
<br />
<br />""._.__J.,
<br />I
<br />I
<br />I
<br />
<br />onsEtllo deslh
<br />
<br />(d)
<br />
<br />.. _..._,__..._____1..
<br />I onset to death
<br />I
<br />I
<br />
<br />19..'WAS MEDiCAL EXAMINERl
<br />
<br />OR CORONER CONTACTED?
<br />
<br />o YES IX NO
<br />
<br />18. PART II.. OTHER SIGNIFICANT CONDITIONS-Conditions contribuling 10 the death but not ra.ulting In the underlying cau.a given In PART I..
<br />
<br />6',? -f?LJ a./~/ca-(/}'/;J #~~~r-",{:? ~1fr'/ j
<br />, ~ ... ftJ .,.,. / 0 ,~ Y-. '/ d? <'-...:: cJ?~"47/Uf7(o-
<br />--.--- "..
<br />210. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />_Nalural 0 Homicide ODrlve,/Operalor
<br />
<br />NOI pregnant within past yaar
<br />o PraQnantalllme of dealh
<br />U Nol pregnanl, but pregnant wllhin 42 deys 01 dealh
<br />Q NOI pregnanl, bUI pregnent 43 day. to 1 year belore death
<br />U Unknown If pragnant wilhln tha pa.1 ya.r
<br />
<br />o AccldenlO Pandlng Inve.lIgallon
<br />
<br />o Suicide 0 Could not be determined
<br />
<br />o Passenger
<br />o Ped..ltlan
<br />W Olher (Specily)
<br />
<br />DYES
<br />
<br />IXNO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />CJ YES U NO
<br />
<br />no. DATE OF INJURY (Mo.. Day, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY.At home, farm, slreel, laclory, oflica building, oonstruotion sita, alc. (Spacify)
<br />
<br />\ m
<br />22d.INJURY',i-i-WOR. K1r.2ia. DESCRIBE HOW INJURY OCCURRED
<br />IJ YES 0 NO_'_J.._
<br />
<br />221. LOCATION OF iNJURY. STREET & NUMBER, APT. NO. CrTYlTOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo" Day, Yr.)
<br />
<br />9, 2006
<br />
<br />240. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />z,"
<br />E~~
<br />".,~
<br />U<l::;
<br />gffi~~
<br />GlZ"
<br />.000
<br />~a::U
<br />8 ~
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo.. Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examination and/or investigation, in my opinion doalh occurred at
<br />Ihatlme, data and placa and due 10 the cau.e('1 stSled. (Signa lure and Title) '"
<br />
<br />2e.. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />2Gb. WAS CONSENT GRANTED?
<br />Nol Appllca~~"1~2.6a i, N~._9_ YES M N~
<br />
<br />NO 0 PROBABLY U UNKNOWN 0 YES lX NO
<br />27. NAME, TITL AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSiCiAN ciii'cOUNTY ATTORNEY) (Typo or Print)
<br />Jane A, McDonald M 800 Alpha St., Grand Island, NE 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />26b. DATE FILED BY REGISTRAR (Mo" Dey, Yr.)
<br />
<br />APR 1 9 2006
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