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<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HE~~f!f!~l!!J-MAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE OR/~,JJl~fi1P.F!~fJLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL&I!f[JmC8:fJ~rfO!!,"WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _,:,~,'_,"~'_'~"'.'" ~..? _."C"._.>.", =. - J~~~l;:~.. -.:~;:.~'_-
<br />
<br />DATE OF ISSUANCE-. .. _. ".'. gJ.-=,,~
<br />
<br />JUN 2 3 2006 200608 435 . \jASStsi~NT::;: JEg/~~~~
<br />LINCOLN, NEBRASKA HEALTH ANQf!'iMAN SEIjlVICES
<br />-,:ATE O~ NEBRASKA - DEP~R~~~;lf~~f;~N~~U~~~I~VICES F~N~ANG(~~~~tpP6b 6...2 6 5 O~
<br />
<br />1. DECEDENT'S-NAME (Fitst, Middle, Last, Sullix) 2, SEX 3, DATE OF DEATH (Mo., Day, Yr.)
<br />Erma Irene Johnson Female May 30. 2006
<br />
<br />~Y AND STATE OR TERR~~ORY~ OR FOREIGN COUNTRY ;F:J BRTH Sa AGE-Last Birthday .s~, UN-DER 1 YEAR 5e. UNDER 1 DAY 6. DATE ~F BIRTH (M-O" D-~~ ".
<br />(Yrs ) M~AYS HOURS MINS.
<br />
<br />Rural Hall County. Nebraska 85 __J__ September 24. 1920
<br />
<br />-- - ----.- - iaaPLACEOFDEATH -
<br />
<br />505-52-4617 J:I.Q.SEIT~~ 0 Inpallem 011:!~. ~NursingHomO/LTC OHosplcoFocility
<br />--.'"--
<br />ab. FACILITY-NAME (If not institution, give street and number) U ER/Outpallom U Decedent's Home
<br />
<br />
<br />Mother Hull Home 0 0Cl'I OOtller(Speclly)___.
<br />-"'-- -~ .", .-,.--
<br />ae. CITY OR TOWN OF DEATH (Include Zip Code) ad. COUNTY OF DEATH
<br />
<br />...
<br />
<br />~
<br />
<br />
<br />.... Keargey 68?47 . Buffalo __ ____
<br />
<br />9., RESIDENCE.STATE: 'J%COBOUuNTvf' f alo ---~TYKOeRaTOrWnN ey -- - -
<br />'- Nebr:~ska_.,._.._. ---.L_ B __1.
<br />
<br />9d.~T;~TA;D.NU~B~:d .-- - J 9-e APT. =--r~~0;:-7---] 99;S~~:CITY~'M~;
<br />w;-,,",,,, -, """' oe o~'" 0-""'00 0 ,~'".",oo I:" ""' oe ,ro", ,,,;,. ,,,". Co". '""", "", "". ""," "_. - --
<br />o Married, bulseparated ~ Widowed 0 Divorced 0 Unknown
<br />
<br />~FATHER'S-NAME~ --------;;;;;;d,e~- Last, SuffIX) E2 MOTHER'S-NAME (Flrsl, Middle, MaidenSurname) --
<br />
<br />-- -- ----.!1yrolL---.:E.. _----.Chadwick" __ _ Estella AI-;linginsmith_
<br />13 EVER IN U S ARMED FORCES? Give date, 01 service il yes. 114a INFORMANT-NAME - 14b. RELATIONSHIP TO D~C~DENT
<br />
<br />(Y""no,o~~ ~_ _ ----1_ _Barbara K Hu~ta __ __ Dll1,1ght~r__
<br />15 METHOD OF DISPOSITION 16a EMBA MER-SIGNATURE .~ _ 16b, LICENSE NO. 16c, DATE (Mo" Day, Yr. )
<br />
<br />lOBurlal o Donation ~~I\ 1199 June 6, 2006
<br />
<br />o Cremation 0 Entombment 16d. CEMETERY, CREMATORY OR OTH~R ~~ CITY I TO-~-" ------s:;-~TE--
<br />
<br />IJ Removal 0 Other (Specify)
<br />
<br />Westlawn Memorial Park Cemetery
<br />
<br />Grand Island.
<br />
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Streel, City or Town, State)
<br />Kleine Funeral Home. 3213 W. North Front St.. Grand Island. NE
<br />
<br />PART l. Enter the .Q.b.aJ..u...Qi"I;!YQD.m..-dlsaases, injuries, or complicalionS--lhat directly caused the death. DO NOT enter termInal events such as cardIac arrest,
<br />respiratory arrest, or ventricular IIbrlllatlon without showing the ellology. DO NOT ABBREVIATE, Enter only one cause on a line, Add additional lines if necessary.
<br />
<br />IMMEDiAtE CAUSE:
<br />
<br />onset 10 death
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease orcondltlofl resulting
<br />In death)
<br />
<br />Sequentially list condltlonS,lf (biD H~&I4...l'Ct
<br />sny, leading to tho CSUae listed DUE TO, Ofi::~'[A t;"ONSE'QUlNCE OF: . --- ....--
<br />on line a.
<br />Entertllo UNDERLYING CAUSE n
<br />(dlaeaseorlnJurythatlnltlatod~tl{),,<i~',ll"e -)l-l-t.J.l~.(;~f47IS \. _
<br />thoeventsresultlng In death) DUE TO, OR ""A CONSEQUENCE OF: r
<br />LASr
<br />
<br />I
<br />~jtj-JP'erHA.f-t:~ ( Ire.-~",j .,4-7-0 fe-1-''lI~4.
<br />DUE TO..6~ AS A CONSEQUENCE OF.
<br />
<br />nJ w e e<'~_
<br />
<br />onset to death
<br />
<br />I
<br />I .d"
<br />-~I!UV-- .
<br />I onsetto&alh
<br />I
<br />I ~?
<br />I ...../-'4 ~~_
<br />ons~ death
<br />
<br />(d)
<br />
<br />18, PART II. OTHER SIGNIFICANT CONDITIONS.Conditlon' contribuling 10 the doalll but not resulling In the underlying cau'e given in PART I.
<br />
<br />o AccldenfD Pending Investigation
<br />
<br />21 b.IF TRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />o Passenger
<br />
<br />U Pedestrian
<br />
<br />TI9.. W AS MEDI~AL EXAMINER"
<br />OR CORONER CONTACTED?
<br />
<br />U YES li NO
<br />-"'.--."""..... .....---
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />
<br />--Pev- k, '^ Sf!.\ ~ 51.; I.'\..ck-pyf\, ~'. f
<br />20. IF FEMALE: '7
<br />I)l.Not pregnanl within past yoar
<br />o Pregnanl at time 01 de.th
<br />o Not pregnant, bul pregnant within 42 days 01 de.th
<br />o Not pregnant, bul prognanl43 days to 1 year belore death
<br />o Unknown II pregnant within the past yaar
<br />
<br />e.~_
<br />
<br />21a. MANNER OF DEATH
<br />,SNalural 0 Homicide
<br />
<br />U YES lllI NO
<br />
<br />o Suicide 0 Could not be determined
<br />
<br />o Other (Specify)
<br />
<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES Ii NO
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />",',---- -'--'.--".
<br />
<br />22b, TIME OF INJURY 22c, PLACE OF INJURY-At home, larm, street, faclory, olllce building, construction site, etc, (Speclly)
<br />m
<br />
<br />-22';-INJURY AT WORK72~~ D~aofll!lf, I&;II;~_RilEO
<br />DYES 0 NO
<br />--- ~~-
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT NO,
<br />
<br />'''''''''''''~:.',oIII''1l',:;-=:,.,''~T~''''7' ~
<br />
<br />CITYJrOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />230. DATE OF DEATH (Mo" Day, Yr.1
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />\~
<br />.-J
<br />~
<br />\-'" )
<br />'--.
<br />
<br />
<br />z
<br />11:!
<br />]!.?
<br />1l~
<br />1i:I;~
<br />e""z
<br />o "'0
<br />u <:
<br />H
<br />~~
<br /><l
<br />
<br />May----3.1L.-2 Qili
<br />23b, DATE SIGNED (Mo., Day, Yr,)
<br />t:, (,- 2. 00 b
<br />
<br />23c, TIME OF DEATH
<br />11:15 P.m
<br />
<br />z>-
<br />1i'~~
<br />H~
<br />ia.oC(~
<br />."'~z
<br />a: 0
<br />'"
<br />"z:>
<br />.coo
<br />~crU
<br />815
<br />
<br />m
<br />
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.1 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examInation and/or Investigation, in my opInion death occurred at
<br />the time, date and place and due 10 the cause(s) statad. (SignalUre and Tillo) l'
<br />
<br />----.9yE~()___1J PROBABLY__U UNKNOWN YES__'::J~_..
<br />27. NAME, TITLE AND ADDRESS OF CERTIFiER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY AHORNEYI (Type or Print)
<br />
<br />Dr. R. Messbar er M.D., 3907 6th ave. Kearne . NE 68847
<br />
<br />29a, REGISTRAR'S SIGNATURE
<br />
<br />26b, WAS CONSENT GRANTED?
<br />Not Applicable It 26. Is NO 0 YES )i NO
<br />
<br />
<br />26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />
<br />006
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