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<br />..
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL'Lff~liUft8MN1 SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGIli!{,.f!$OIfQJ'fj~/LE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL s1fi;I~1~Jti.~p71i:jNj.; V(JfICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. # ';j,,-'.:,,~;-=c~- i~/1":':'.L,
<br />
<br />DATE DF ISSUANCE ~~I~ER
<br />
<br />~7!D~N\~gg~SKA ,200608127 ~~Jrr.:~~~
<br />
<br />
<br />.."'. -..-.
<br />.---.
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<br />STATE OF NEBRAsKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND Sf!PPOF}ll6 2 9 7 Q. 9
<br />CERTIFICATE OF DEATH U '
<br />____.._,___,__.~"..,.,.~~,~_ ..._, ___.m.'~'~."'_ ~_~ ,. .
<br />
<br />1. DECEDENT'S.NAME (Firsl,
<br />Robert
<br />
<br />Middle,
<br />James
<br />
<br />Last!
<br />Johnson
<br />
<br />Sulllx)
<br />
<br />2,SEX
<br />Male
<br />
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 26, 2006
<br />
<br />4. CIl'y AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Ayr, Nebraska
<br />
<br />5a, AGE-la" Birthday 5b. UNDER 1 YEAR
<br />(Yro.) MOS. DAYS
<br />80
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6, DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />March 3, 1926
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />505-26-6489
<br />
<br />8a. PLACE OF DEATH
<br />
<br />H.Q.SflIAl.:
<br />
<br />~ Inpali.nl
<br />
<br />QII:IEB: !Ill Nurolng Home/LTC U Hospice Facilily
<br />
<br />8b, FACILITY.NAME (II not institUlion, give str.el and number)
<br />
<br />U ER/Oulpatlenl
<br />
<br />o D.c.dent's Home
<br />
<br />St. Francis Skilled Care
<br />
<br />Dm\
<br />
<br />U oth.r ISpecily)
<br />
<br />ao. CITY OR TOWN OF DEATH (Include Zip Cod.)
<br />Grand Island
<br />
<br />68803
<br />
<br />ad, COUNTY OF DEATH
<br />Hall
<br />
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />
<br />9b, COUNTY
<br />Hall
<br />
<br />
<br />91. ZIP CODE
<br />68803
<br />
<br />9g, INSIDE CITY LIMITS
<br />Xl YES 0 NO
<br />
<br />Second
<br />
<br />o Never Married
<br />
<br />lOb, NAME OF SPOUSE (First, Middl., Last, Suffix) tI wile, give maiden Mme,
<br />
<br />o Married, bul separaled 0 Widowed 0 Divorced U Unknown
<br />
<br />Merleen Geisert
<br />
<br />11. FATHER'S-NAME (FirS!,
<br />
<br />James
<br />
<br />Middle,
<br />P.
<br />
<br />Last,
<br />Johnson
<br />
<br />Suffix)
<br />
<br />12, MOTHER'S-NAME (FlrSI,
<br />Neva
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />Connely
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />13, EVER IN U,S, ARMED FORCES? Give dales ot service if ye" t4a.INFORMANT.NAME
<br />(Ye"na;-~fiM) 6-7-1944 5-19-1946 Merleen
<br />
<br />o Cremalion 0 Enlombmenl
<br />
<br />t 6a. EMBALMER-SIGNATURE
<br />
<br />
<br />;6d:CEM.ETEAY'~~~CATION
<br />
<br />Johnson
<br />------T6b, LICENSE NO", /3"z s-
<br />
<br />CITY / TOWN
<br />
<br />16C, DATE (Mo" Day, Yr,)
<br />S~Jl.~_e:mber 1, 2006
<br />
<br />STATE
<br />
<br />15, METHOD OF DISPOSITION
<br />iXaurial U Donation
<br />
<br />o Removal U Olher (Speclly)
<br />
<br />Blue Valley Cemetery
<br />
<br />Ayr,
<br />
<br />Nebraska
<br />
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (Slreet, City orTown, Slafe)
<br />Apfel Funeral Horne, 1123 West Second,
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />PART I. Enter the ~~".dlseases, Injuries, or oompUce:llons--that directly caused the death. DO NOT enter t8rminalevBnts such as cardiac arres!,
<br />respiratory arrest! Or ventricular tibrillallon wllhout showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a llna. Add addltlonalllnes If necessary,
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl.ea.e or condition re.ultlng
<br />In death)
<br />
<br />(.) 1t117 AS 7A1.t~_c.wl1'V"M4
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I
<br />I
<br />
<br />I onse\\o death
<br />I
<br />
<br />Or /~"t41[_____..~_:....-.d y,(J'
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onsst to death
<br />
<br />Sequenllelly 11.1 <ondlllon., II (b)
<br />any, leading 10 the cau.e listed DUE TO, OR AS A CONSEQUENCE OF:
<br />on line 8.
<br />Enterthe UNDERLYING CAUSE
<br />(dl..... or Injury that Initialed (e)
<br />th..ventsr..ultlng In death) DUE TO, OR AS A CONSEOUENCE OF:
<br />LAST
<br />
<br />onset to death
<br />
<br />onsel to death
<br />
<br />(d)
<br />
<br />CNr /111}1/J
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORDNER CONTACTED?
<br />DYES 1..P40
<br />
<br />18, PART II, OTHER SIGNIFICANT CONDITIONS-Conditions contributing 10 the dealh but nol re,ulling in Ihe underlying caus. given in PART I.
<br />
<br />o Not pregnant within past year
<br />o Pregnant al time 01 death
<br />o Not pregnant, but pregnanl within 42 days 01 death
<br />o Not pregnant. but pregnanl43 days to 1 year before death
<br />o Unknown il pregnant within the past y..r
<br />
<br />o AccidenlO Pending Investigation
<br />
<br />21b, IFTRANSPORTATION INJURY
<br />o Drlver/Operalor
<br />
<br />U Passenger
<br />
<br />o P.d.strlan
<br />
<br />o Olher (Specify)
<br />
<br />21c, WAS AN AUTOPSY PERFORMED?
<br />
<br />20, IF FEMALE;
<br />
<br />2ta. MANNER OF DEATH
<br />~elural 0 Homicide
<br />
<br />DYES
<br />
<br />~O
<br />
<br />U Suicide 0 Could not be determined
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />22a, DATE OF iNJURY (Mo" Day, Yr,)
<br />
<br />22b. TIME OF INJURY 22;, PLACE OF INJURY-AI home, larm, slreel, taclory, ollice building, construction ,i1e, elc. (Specify)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />22e, DESCRIBE HOW INJURY OCCURRED
<br />
<br />
<br />DYES 0 NO
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYffOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a, DATE OF DEATH (Mo" Uey, Yr.)
<br />
<br />t;?lJJ -<?/!._____. __ ___.
<br />
<br />24a DATE SIGNED (Mo" bay, Yr,)
<br />
<br />24b, TIME OF DEATH
<br />
<br />Z
<br />~:!
<br />",!.l
<br />U?
<br />'6..:E:::i
<br />Eo.Z
<br />" 010
<br />... c
<br />1!'g
<br />~~
<br />00:
<br />
<br />
<br />,..~i:i
<br />.o~~
<br />hI'!
<br />tif!d:~
<br />E"',..Z
<br />8iliizo
<br />1!Z=-
<br />~~8
<br />813
<br />
<br />m
<br />
<br />240. PRONOUNCED DEAD (Mo" Dey, Yr,) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examinatIon and/or Investigation, in my opinion death occurred at
<br />Ih. time, dale and place and due 10 Iho caus.(s) stated, (SlgnalUre and Title) y
<br />
<br />25. DID TOBACCO USE CONTRIBUTET.OTHE DEATH?
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b, WAS CONSENT GRANTED?
<br />Nol A~pticable It 26e Ie NO 0 YES..)( NO..
<br />
<br />U YES gNO 0 PROaABLY 0 UNKNOWN 0 YES rj(1\j0
<br />27.NAME, TITLE ANDAOORESS-OFCERTiFiER (PHYSICIAN, CORONER'S PHYSICIAN OR'cour.J'ifATfORNEY) (Type or Prlnl)
<br />David Colan M.D. 729 N. Custer, Grand Island, NE.
<br />
<br />
<br />
<br />~ .. """-,,-,,
<br />
<br />
<br />68803
<br />28bSEP'~ED B7 RZOOR6\(MO" Day, Yr,)
<br />
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