|
<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />$YSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECQ8f1...f)l..lF/LE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlST~~_~:~lf;H IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~:-~~" .::~,~1'i=1t~-":~~_
<br />
<br />DATE OF ISSUANCE , _, ~.. ~~ =~
<br />rE 609 519 ~ -:-' l'ANtE!ts.' cckiPER
<br />r 8 2 8 2006 200 ASSISTiVir srAiEcREGISrRAi:t
<br />LINCOLN, NEBRASKA HE~iH'AND RUMA"!$EflviCES
<br />
<br />~
<br />
<br />i~~{ 1, DECEDENT'S-NAME (FIr~~mPton Mi~le, D~~brow
<br />
<br />..~rl---~',- C-I;Y AND STATE OR TERRITORY, OR FOREIGNCOUN~;lYOF BIRTH 5a. AGE-Last Birlhday
<br />:\I~ . (Yrs.)
<br />'IE~~ Omaha, Nebraska 91
<br />
<br />~'~f~ 7. SOCIAL SECURITY NUM-BER 8a, PLACE OF DEATH
<br />:~!*t;:, 5 0 7 - 16 - 2 8 1 0 !:iQ.SffiAl.
<br />Ir::~i __.. .._, n'_____ _________
<br />,.'.111' ''i.....I.'.. 8b, FACILITY-NAME (If nol Institution, glva slreet and number)
<br />'~ ,~;
<br />II St. Francis Medical Center
<br />1(' W~'
<br />!~I5I~1 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />I k ,,"'.::::: Mand
<br />'1.,1 "w.' Nebraska
<br />..?"",
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FfNA,~C:~AN,El$l#>I>6RT.O 6 218 6 4
<br />CEF!TIFICA!~ o F__[)EATH __ ___~:~.._-,. __~__nu____
<br />
<br />
<br />Suftix)
<br />
<br />3. DATE: OF DEATH (Mo., Day, Yr,)
<br />February 17, 2006
<br />
<br />6, DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />December 13, 1914
<br />
<br />I2l. Inpatient
<br />
<br />Q:IJ:illj: 0 Nursing Hom./LTC 0 Hospic. Facility
<br />
<br />W ER/Oulpatient
<br />
<br />U Decedanl'S Home
<br />
<br />OM
<br />
<br />o Olher (Speclly)____.__ ...
<br />
<br />68803
<br />
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />
<br />9b COUNTY
<br />Hall
<br />
<br />
<br />91. ZIP CODE
<br />68803
<br />
<br />9g, INSIDE CITY LIMITS
<br />
<br />Xl YES 0 NO
<br />
<br />
<br />9d. STREET AND NUMBER
<br />1511 N. Huston Ave.
<br />
<br />10.. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Merried lOb. NAME OF SPOUSE (Firsl, Middl., Last, Sulflx) II wll., give meiden name.
<br />
<br />o Married, bUI sepereled ~Wldowed 0 Divorced 0 Unknown
<br />
<br />1UATHER'S-NAME (F~~rry Middle, D~:~row __~U-I~~:=I~; MOTHER'S,NAME ~:;'ie
<br />
<br />13. EVER IN U,S, ARMED FORCES? Give dales 01 service If yes. 14a.INFORMANT.NAME
<br />(Yes, no, orunk,) Yes: WWII 1942-1944 Sandra Disbrow
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />
<br />Hampton
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter In Law
<br />
<br />15. METHOD OF DISPOSITION 15e, EMBALMER-SIGNArURE 16b. LICENSE NO, 16c. DATE (Mo., Dey, Yr. )
<br />o Burial o DonaHon #It/~ -Z > February 20, 2006
<br />cXcremalion o Entombment CITY !TOWN STATE
<br />o Removal Ll Olh.r (Specify) Westlawn Memorial Park Grand Island, NE
<br /> Crematory,
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Streel, Cily orTown, State)
<br />Apfel Funeral Home, 1123 West Second,
<br />
<br />Grand Island, NE
<br />
<br />
<br />18, PART I. Enler Iho chllin.ciA~--dlseases, injuri.s, or complic.tlonsnlhat directly caused Ihe deeth. DO NOT enter termlnalevenls such as cardiac arreSl,
<br />respiralory arr.st, or ventricular fibrillation without showing Ihe e.tlology. DO NOT ABBREVIATE. Enler only ona cause on a line. Add addillonallin.s If n.cassary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl.eas. or condlllon resulllng
<br />in death)
<br />
<br />(a)
<br />
<br />
<br />I
<br />I
<br />
<br />I onsello dealh
<br />I
<br />IS'"
<br />
<br />'''.''1 -t:.~
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset 10 death
<br />
<br />'7
<br />(t..C'_--, ./,/
<br />t
<br />
<br />S.qu.ntlally list condlllon.,If (b)
<br />any, loading to tho cous.lI.t.d -- 'DlJE-i-O:OR -AS A CONSEQUENCE OF;
<br />on line a.
<br />Enter tho UNDERLYING CAUSE
<br />(dl..... or Injury that Initiated (c)
<br />th.eventsro.ultlnglnd.oth) DUE TO, OR AS A CONSEQUENCE OF;
<br />lAST
<br />
<br />....-----'------
<br />onsello d.alh
<br />
<br />ons.llo death
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Condlllons conlribullng to the death bul not resulting in Ihe underlying cause given In PART I.
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES
<br />
<br />o NO
<br />
<br />...~.'
<br />1
<br />'CI.
<br />E
<br /><'3
<br />hu':
<br />1,&' _
<br />'I.~
<br />'.I..,.........~........
<br />.'~)it
<br />
<br />20, IF FEMALE;
<br />o Not pregnant wllhln paSI year
<br />o Pregnenlal time 01 death
<br />o NOl pregnant, but prognanl within 42 days 01 death
<br />o Nol pregnant, bul pregnanl43 days fo 1 year belore d.ath
<br />U Unknown If pregnanl within Ihe past year
<br />
<br />21a, MANNER OF DEATH
<br />)i1ialural Ll Homicide
<br />
<br />o AccldenlO Pending Invostigation
<br />
<br />o Suicide 0 Could not b. d.tormined
<br />
<br />21b.IFTRANSPORTATION INJURY 21c, WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />U P..eenger
<br />o Pedestrian
<br />o Other (Sp.cify)
<br />
<br />DYES
<br />
<br />XNO
<br />
<br />21 d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />U YES 0 NO
<br />
<br />22a. DATE OF INJURY IMo" Day, Yr.)
<br />
<br />
<br />22b, TIME OF INJURY 22c. PLACE OF INJURY-AI home, farm, stre.t, lactory, olllce building, con'lrucllon ,Ite, etc. (Speclly)
<br />m
<br />
<br />22d.1NJl1IlY AT'I'IOIlK7'"
<br />
<br />~(:'::t;:)
<br />
<br />
<br />221. LOCATION OF INJURY.. STREET & NUMBER, APT. NO,
<br />
<br />CITYlfOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />z)..
<br />$~~
<br />'Ccn~
<br />23c, TIME OF DEATH II n ~
<br />d a.D..4;~
<br />, 'J m E "'.,"1': 25
<br />23d. To tho basi of rnY!knowledge, dealh.occurred at the lime, data and place 8 Z 24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />and due 10 tho cause(s) stated'J(SlgnJ-lur~ and Title) ... ~ 25 8 Ihe time, dale and place end due to Ihe cause(s) statod. (Signa lure and Title) ...
<br />
<br />l\."j.-A:::--- I- 8 5
<br />
<br />25 DIDTOBACCOU ONTR/BUTETOTHEDEAiH? 26a, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />
<br />~:,~ITLE~d6~DDR~:6~~~~~FIER~P~:S~~~~~ORONER~ P~~~ICIAN OR COUN~~~RNEY) (Typ. or p~';~--- _.!l~t!J~H<:_.bl. If 28a is NO 0 YES 0 NO
<br />Gordon Hrnicek,M.D. 729 N. Custer, Grand Island, NE.
<br />
<br />240, DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />240, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />
<br />24d. TIME PRONOUNCED DEAD
<br />
<br />m
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />68803
<br />
<br />28a, REGISTRAR'S SIGNATURE
<br />
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />FEB 2 4 2006
<br />
|