|
<br />'~
<br />
<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTIjANDHJ.JIVI~ttSERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIG/~Af-_R{:(;f)JffUIN~4EWITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL S~T~~~,,-WI1!CH IS
<br />THE LEGAL DEPOSITORY FOR V~TAL RECORDS. ~~=.r~.:o.<;;-' j .., - ~ /}iZ-..)~~,
<br />
<br />DATE OF ISSUANCE - . _- _cfh =~ _0
<br />
<br />OCT 2 4 2006 20 0 611 0 6 9 'ASS/S;AN::~i.::~gi~t~:
<br />LINCOLN, NEBRASKA HEAL THANe 11}IMAJIlSEttVICES
<br />---
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES:FINANCE A'ND SUPPO~ C ':)13 4 2
<br />------- --___ CERTIFICATE OF DE~TH _U_~.
<br />DECI':DENT'S.NAME (First, Middle, La't, Suffix) 2, SEX 3_ DATE OF DEATH (Mo" Day, Yr.)
<br />
<br />--------Haro~-~n~-----.E.er-IY---
<br />4_ CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa, AGE.Last Blrlhday 5b_ .UNDER 1 Y~AR _ 50, UNDER 1 DAY 6_ DATE OF BIRTH (Mo" Day, Yr.)
<br />
<br />~olbach, Nebraska (Yrs,) 74 MOr-HOURS MINS, ovember 1, 1931
<br />
<br />
<br />:~~:~~,!~~:~,~~, '''M''''''"" ".. ""., ,,,' ~"~"",. .=r.... 8a :~~:I~:I DEATH- C4 Inpatianf Ql1iEB LI N"~':9 Homa/LTc- ~ Hospice F.Cili~
<br />
<br />o ER/Outp.llenl 0 Decedent', Home
<br />Francis Medical Center
<br />o CO'\ 0 Olher (Specify)_.
<br />
<br />Bc_ CITY OR TOWN OF DEATH (Include Zip Code) - - ~COUNTY OFHDEaATIH-I -
<br />Grand Island 68803 ___.I
<br />
<br />N9~~;:N~E::~ --r~:~ --- ?~Y;~~W~ ~sland- ---- -
<br />
<br />9d STREET AND NUMBER ----- ------rge -APT, NO r 9f ZIPCOD~ ~IDE-CITYLIMITS
<br />8?~un Valley D!~ ___ __----.L ---.16_8801 __I ~ 0 NO
<br />tOa MARITAL STATUS AT TIME OF DEATH Xl Married 0 Never Married -r::;MI': OF SPOUSE (First, Middle, Lasl, Suffix) If wile, gl~e maiden name, -
<br />
<br />IJMarrred,bUlseparated OWldowed ODlvorced OUnknown reanor Trosper
<br />
<br />11, FAHfER'S-NAME -- (F~S~- Middle, Last, S..U IIIX) EM.. OTHER'S'NAM. E (First, Middla, -Maiden Surname)
<br />
<br />- _~_r!l-est Jam~s Perry"'--_. ____~;tella Mae _ Marr_~ _
<br />13 EV~R IN US ARMED FORCES? Give dale' of serVice if yes 14a INFORMANT.NAME ~4b RELATIONSHIP TO DECEDENT
<br />
<br />(~~~run~/1952-.1/1l954 Eleanor Perry Wife
<br />-15 METHOD OF DISPOSITION 16a, :~BALMEA'SIG - AT~' - - ~-;;NSE NO, -- 16c DATE (Mo, Day, Yr ) -
<br />
<br />JOB"rlal [JDonatlon \)It/,CH.',' l.h ____ __~_8 __ October 16,2006
<br />
<br />U Cremation U Entombment 16d CEMET Y, CREMATORY OTHER LOCATION CITY / TOWN STATE
<br />
<br />Male.__
<br />
<br />tohar_J 2 .
<br />
<br />2006
<br />
<br />o Ramoval 0 Other (Specify)
<br />
<br />Westlawn Memorial Park Cemetery, Grand Island, Nebraska
<br />
<br />11a, FUNERAL HOME NAME ANO MAILING ADDRESS (Slreet, Clly or Town, State)
<br />All Faiths Funeral Home, 2929 S.Locust
<br />
<br />PART J. Enl@r the Cha1n.Qt...ID~~..!].1s..-djseases, Injuries, or complicationS--lhal directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respirafory arrest, or ventrIcular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enler only one cause on a IIna. Add additional [lnes if necossary,
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDI~7CAUSE: ~)" .
<br />
<br />IMMEDIATE CAUSE (Final (e) i~eAt.J1~t~Vivi--t)"L'" . J',.l't:.L
<br />dl,easeorcondltlonreoulting DlJETO, OR AS A CONSEQUENCE OF: .------.
<br />
<br />~ne:::::ielly IIs1 oondlllons, if (b) ;4ld"t<..~f 1f!e.~?/~ltJ1lv7e /ll1 ~e4~J
<br />
<br />any, leading to Ihe oau.ell.ted - -DUE TO, OR AS A CONSEQUENCE OF: ---- ,~--.
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(dl$ease or Injury fhat Initiated (c)
<br />the E1vent$ resultIng in dealh)
<br />lAST
<br />
<br />I
<br />
<br />_.._~ ~~L.c2tL'-t2-
<br />
<br />I on,atto death ,.
<br />I ~. /,,:1
<br />: ~-MI?VJ _
<br />
<br />I onset 10 death
<br />I
<br />
<br />onset to dea!h
<br />
<br />
<br />-----L.__
<br />I onsello death
<br />I
<br />M I
<br />
<br />I;,,;ARTII OTHER, S~-NIFIC~N~~ONDlTIo~s~~ondit::n:lcont"bUting; th:;}athbut no~;es~~n~; the underly:.cauoe glvon In PA~ '-PO:A;O:~~~~LC~::~~:D? -
<br />L/fvI/--f;J I-v'r't:! (fL.-a.IL-r J:!-"J~ltM-t.v'( ytt1A-,,(.~, --.L ~ YES ~ NO
<br />
<br />- 20 -'F FEJ1E - 21;f. " NER-OFDEATH -- 21b IF TRANSPORTATION INJURY 21c WASANAUTOPSYPE~FORM~
<br />
<br />o Not pregnant within past year Natural U Homicide 0 Drlver/Operalor ~
<br />' - , OPessen er 0 YES NO
<br />o Pregnant altima of death U AocldanlU Pending Investigation 9 .._______
<br />
<br />o Not pregnarH, but pragnantwithin 42 days of death 0 Suicide 0 Could not be delermined 0 Pedestrian 21d, WERE AUTDPSYFINDINGS AVAILABLE TO
<br />O U Olher (Specify)
<br />_ Not pregnant, but pragnant43 days 10 1 year belore dealh COMPLETE CAUS~9F DE. ATH?
<br />
<br />o Unknown if pregnAnt within tha pa!11 year ._._ 0 YES ~O
<br />
<br />~ ~-DATE ~r INJUflV~, Day, TT) ~ - --I rn.---miEOF ~PLACl:Ul"INJl!l'iY'Ai home'-l~m:St;;;it:l.otory: omc'-bulldlng, conslruction olle, elc (SpeOlfY)"'''
<br />
<br />
<br />-Ud INJURYATWORK' ] 22e DESCRIBE HOW INJURY OCCURRED -- --- -- - - - --~- --
<br />o YES U NO
<br />--- --- -------.
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO_ CITYlfOWN STATE
<br />
<br />DUE TO, OR AS A CONSEQUENCI': OF:
<br />
<br />ZIP CODE
<br />
<br />23a, DATE OF DEATH (Mo., Day, Yr,)
<br />
<br />24a_ DATI': SIGNED (Mo., Day, Yr,)
<br />
<br />24b, TIME OF DEATH
<br />
<br />
<br />z
<br />><
<br />iQ
<br />1ii~)-
<br />'Q,::J:.,J
<br />Ea.z
<br />0<1>0
<br />~ ~
<br />.s'"
<br />~~
<br /><
<br />
<br />
<br />OctQber_ll,_
<br />23b_ DATE SIGNED (Mo" Day, Yr.)
<br />October 16,2006
<br />
<br />23c_ TIME OF DEATH
<br />19:11 p.m
<br />
<br />z>
<br />~~~
<br />:gin'"
<br />w~~
<br />Q.c..-:c~
<br />E ~VI 2: ;iil:
<br />8[5,,0
<br />.sz:>
<br />~~8
<br />o~
<br />()o
<br />
<br />m
<br />
<br />24c_ PRONOUNCED DEAD (Mo" Day, Yr.) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On !he basis of examination and/or Investigation, in my opinion daath occurred at
<br />Iha tima, date and place and due 10 the cau,e(o) stated, (Signalure and Tilla),.
<br />
<br />25, DID TOBAQCO U CONTRIBUTE TO E DEATH' 26a, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 26b, WAS CONSENT GRANTED?
<br />
<br />o YES I ... NO OPROBABLY~OWN I] YES .J NO _~ Not Applic~~le If 26. is NO. DYES U NO
<br />-27', NAME, TITLE AND ADDRESS OF CERTIFIER (pHYSICIAN, CORONER'S PHYSICIAN ciA ~ORNEY) (Type-~; P;int)
<br />J.A. Wagoner M.D., 800 Alpha, Grand Island, Nebraska 68803
<br />
<br />28a_ REGISTRAR'S SIGNATURE
<br />
<br />
<br />2Bb_ DATE FILED BY REGISTRAR (Mo_, Day, Yr.)
<br />OCT 2 0 2006
<br />
|