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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANJJ.:l:IfJMA'N..SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAl::.jfECtNWt.1N-j::jt'EoWITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATt$ffICSICTlON/ViHidH IS
<br />
<br />::~:::~:~::~TORY FOR YffAL RECOROS.It.-T:2l;,~\
<br />NOV 1 3 2006 JVr'ICi1TANijY-S.cCdOPEB
<br />2 0 0 61 0 7 5 7 A58I$iA~T srArt! RJdlSfRAR
<br />LINCOLN, NEBRASKA HEI.J.T,ftA~~fI#J:(v.1i;Es
<br />, ".', ~-.~'~:"=,~~~ '. :..~,~;.,:':~::,,:~l~s~:~~~'~
<br />- .,~ ~. =:":~~~,.=~~~:::-' ';..~-
<br />
<br />STATE OF NEBRA.'. SKA - DEPARTMENT OF HEA.LT.. .H....AND HUMAN SERVICES FINANCE.AND SUPP. Oll{. 6 320 8..5.. .,.
<br />_., _._ CERTIFI~ATr; OF DEATH..n ' _.U.
<br />Middle, Last, SUffix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />August. Janssen Male Novemb~:r:. 4, 2006
<br />
<br />)
<br />!
<br />I
<br />I
<br />I
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />(First,
<br />Herman
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ericson, Nebraska
<br />
<br />Sa. AGE.Last Birthday 5b. UNDE'R 1 YEAR
<br />~rs.) 71 MOS. DMS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS [MINS.
<br />
<br />6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />July 5, 1935
<br />
<br />6a. PLACE OF DEATH
<br />~;
<br />
<br />7. SOCtAL SECURITY NUMBER
<br />505-52-5617
<br />
<br />Q Inpatien'
<br />
<br />OII:JEB; Xl Nursing Home/LTC Q Hospice Facillly
<br />
<br />FACILITY.NAME (If not Institution, give street and number)
<br />
<br />U ER/Outpatiant
<br />
<br />o Decedent's Homo
<br />
<br />Beverly Healthcare at Lakeview
<br />
<br />U CO'\ 0 Other (Spacify)_~
<br />
<br />-'. ..18d.COUNT~:~~TH
<br />
<br />9c. CITY OR TOWN
<br />Grand Island
<br />
<br />.J.ga APT.N~.. 81. ZIP c~D;80 1
<br />
<br />
<br />lOb. NAME OF SPOUSE (First, Middle, L.st, Sufllx) It wife, give melden neme.
<br />
<br />8c. CITY OR TOWN OF DE'ATH (Include Zip Code)
<br />Grand Island
<br />
<br />68801
<br />. 19b'COUNTY Hall
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />IXI YES 0 NO
<br />
<br />9.. RESIDENCE.STATE
<br />
<br />Nebraska
<br />
<br />9d. STREET AND NUMBER
<br />
<br />660 E.ast Ashton
<br />1 Oe. MARITAL STATUS AT TIME OF DEATH (l{Married LJ Never Married
<br />
<br />iJ Married, but separatad 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Carolyn A. Poppe
<br />
<br />11. FATHER'S.NAME (First,
<br />Otto
<br />
<br />Last, Suffix)
<br />Janssen
<br />
<br />12. MOTHER'S.NAME (Firs\,
<br />Ethel
<br />
<br />Middle,
<br />
<br />Maiden Surn.me)
<br />Pratt
<br />
<br />Middle,
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />13. EVER IN U.S. ARMED FORCE'S? Giva d.t.s of ..rvlce II yes. 14a.INFORMANT.NAME
<br />
<br />No Carolyn A.
<br />
<br />Janssen
<br />.- C.L1CENSENO#/T.?.J
<br />
<br />CITY / TOWN
<br />
<br />160. DATE (Mo.. Day, Yr. )
<br />
<br />November 8, 200~_
<br />
<br />STATE
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />16a. EMBALMER.SIGNATURE' ,
<br />
<br />z::~
<br />
<br />16d. CEMEToRY, CREMATORY OR THER LOCATION
<br />
<br />Q;,Buri.1
<br />
<br />o Donallon
<br />
<br />U Cremation 0 Entombmenl
<br />
<br />o Removal 0 Oth.r (Specify)
<br />
<br />Greeley Cemetery
<br />
<br />Greeley, Nebraska
<br />
<br />17b. Zip Code
<br />
<br />(Slreel, City or Town, State)
<br />
<br />1123 West Second, Grand
<br />S.
<br />
<br />
<br />68801
<br />
<br />18. PART I. Enter the chAin 01 evenls--diseases, injuries! Or compllcallons--thal directly caused the death. DO NOT enter terminal events suoh as cardiac arrest,
<br />respiratory arrest I or ventricular fibrillation 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 />I
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<br />I onsel to death
<br />
<br />;, ~.~4a/' .h'~1..-,_4~~,-<~,/dO/~: ..~~7
<br />
<br />QUENCE' OF: ""'7 ,/ I on.et to death
<br />I
<br />I
<br />~, ;-fl.0..j'1. ':~,~ .
<br />I onset to death
<br />I
<br />
<br />o
<br />
<br />tMMEDIA TE CAUSE (Final
<br />disease or condition resulting
<br />In doath).
<br />
<br />(a)
<br />DUE TO, OR AS A CON
<br />
<br />(b) . ~.!J2 d<i?<,.;'@(".:::-,.q.c;2<~ A6'~9/""
<br />DUE TO, OR AS A CONSEQUENCE'.6F~
<br />
<br />
<br />Sequentially list conditions, If
<br />any, leading to the c:aU$e listed
<br />on line 8.
<br />Ent.rthe UNDERLYING CAUSE
<br />(dl..... or Injury that Inltl.t.d
<br />Ihe ovonto rosulllng In deeth)
<br />lASf
<br />
<br />
<br />/
<br />
<br />I
<br />_.1..
<br />I onsello dealh
<br />
<br />(c)
<br />
<br />DUE TO, OR AS A CONSEQUENC~ OF/ '
<br />~1/ r-/10 /../.vv~ Cc.J""-':>..<q /'..,r~ ~-"r:~.Jr::
<br />(d) '<:""t:~/--"?. 09
<br />18. PART II. OTHER StGNIFICANT CONDITIONS.Conditlons contributing to the dea t not resulling in tha underlying causa givan in PART.
<br />!?/
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CO. TACTEP?
<br />
<br />iJ YES No
<br />
<br />20. IF FEMALE:
<br />o Not pragnant wllhln past yaar
<br />U Pregnant .ttime of death
<br />o Nol pregnant, but pregnant within 42 days of dealh
<br />o Not pragnanl, but pregn.nl43 daystn , ya.r belor. dealh
<br />U Unknown if prognant wittlin Ihe past year
<br />
<br />21 a.,. MM?N NNER OF DEATH
<br />',~atural 0 Homicide
<br />
<br />21b.IFTRANSPORTATION tNJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operalor \/
<br />
<br />o Pessengar 0 YES ft NO
<br />
<br />U Aoold.ntD Pending Invastig.tion
<br />
<br />o p.destrl.n
<br />o Dthar (Speolly)
<br />
<br />21d. WERE AUTOPSYFINDINGS AVAtLABLETO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES U NO
<br />
<br />o Suicide 0 Could nol be determined
<br />
<br />
<br />22d.INJURY AT WORK?
<br />
<br />
<br />ZIP CODE
<br />
<br />22a. DATE OF INJURY (Mo., D.y, Yr.)
<br />
<br />22b. TIME OF INJURY 220. PLACE OF INJURY.At home, lerm, streat, I.ctory, o/lloe building, oonstructlon .110, 010. (Spaolfy)
<br />
<br />m
<br />
<br />U YES 0 NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />NQY~lClbe..t'_.~l t
<br />23b. DATE SIGNED (M~ D.~ Yr.)
<br />Novembero,L006
<br />
<br />24.. DATE SIGNED (Mo., D.y, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
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<br />
<br />230. TI~ OF .QEATH
<br />~:~O a m
<br />
<br />24c. PRONOUNCED DEAD (Mo.. D.y, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examination and/or invBstigalion1ln my opinion death occurred at
<br />tha time, d.te end plaoa and dUB to th. o.use(s) stated. (Sign.ture and Tille) "
<br />
<br />28b. WAS CONSENT GRANTED?
<br />Not AppILo!'.~~e If 26a Is NO D~.E~.. ~O
<br />
<br />25.DIDT ACCO USE CONTRIBUTETOTHE DEATH?
<br />
<br />DYES L.l NO 0 PROBABLY UNKNOWN U YES Icl NO
<br />27. NAME;'TITLE AND ADDRESS OF-CEATtFIE HYSIC1AN,'CORONER'S PHYSICIAN OR COUNTfAl'TORNEY) (Type or PrInt)
<br />Jane McDonald M.D. 800 N. ALpha Ave., Grand Island,
<br />
<br />NE. 68803
<br />
<br />28e. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />NOV
<br />
<br />8 2006
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