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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUM"AN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL H~ORO:ONFtt:E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlS1'lCfiSEtiiOf.J;Wtiif:H./S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS'~~~'i~}r~5~1
<br />
<br />
<br />D;~~BOF~S;U;~~; P1'}T~~6~~
<br />ASSJ$TA~T STATE REGlsTlfAf!
<br />HEACttt ANQ RUMA_NcSERVlCEs
<br />
<br />200701059
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />
<br />
<br />STAT. E..OF. NEBRASK.. A. ..-.. OEPARTME. ..NT OF HEALTH.. ....A. ND HUMAN.. SERVICES FINANCE AND sUPP..OI}\.., .2 0 6 8.7
<br />__ __. CERTIFICAIE OF DEATIL _..-~_ __~
<br />
<br />1,DECEDENT'S-NAME (First, Middle, Last, Sulflx) 2, SEX 3, DATE OF DEATH (Mo" Day, Yr.)
<br />~.J3tanley Nolan ~affertyr:!.ale _ anuary 22,___2007
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-La,t Blrlhday 5b. UNDER 1 YEAR 5c, UNDER t DAY 6. DATE OF BIRTH (Mo" Day, Yr.)
<br />North Platte, Nebraska (Yr..) 7 5 MOS DAYS -HOu:J MINS._ ept. 27, 1931
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />505-32-0942
<br />
<br />8a, PLACE OF DEATH
<br />J::lQ.SE.LTAL: Illi Inpatient
<br />
<br />QiliES: 0 Nursing Homa/LTC U Hospice Facility
<br />
<br />8b_ FACILITY.NAME (If nol Inslilution, give streel and number)
<br />Francis Medical Center
<br />
<br />o ER/Oulpalient
<br />
<br />o Decedent's Home
<br />
<br />"J'9b-COUNTY .-.....-
<br />Hall
<br />.. -
<br />
<br />o WI U Other (Specily)__
<br />~8d'COUNTYOFDEATH Hall
<br />
<br />~ORTOWN G;and ~-~land
<br />-- Ie. AP~NO 9f ZIP CODE
<br />_68803
<br />--- -- ----
<br />tOb, NAME OF SPOUSE (Flrsl, Middle, Last., Sullix) II wile, give maiden name_
<br />
<br />--=n- 9g_iNSIDE CITY LIMITS
<br />)b YES U NO
<br />.- _.----".-
<br />
<br />~Married 0 Never Mwled
<br />
<br />Nancy Jameson
<br />
<br />__, _. Wil_lia~ Mi*I:'Raf~:";'rt; SUIfI~:_]12.MOTHER'S-NAM~ri~~e F;i~~ _ Gla~a~ensurname)
<br />
<br />13.. EVER IN U.'S.'. A...R..MED FORCES? Give dates OI.e'.Vie.e. if yes_ E' INF..ORMANT-NAME '. 34b RELATIONSHIP TO DECEDENT
<br />
<br />_(Yes,no,or~~-) _NO __ __ n ___ Nancy RafferC'-- wife_ -~--
<br />15. METHOD OF DISPOSITION 160. EMBALMER.SIGNATURE 16b LICENSE NO 16e DATE (Mo , Day, Yr )
<br />ClSurial o Donalion Not Emba~.med _ Jan~! 2007
<br />
<br />Qg:Cremalion [J Enlombment l6d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />
<br />URemoval OOll1er(Specily) Central Nebraska Cremation Service, Gibbon, Nebraska
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Streel, City or Town, Stale)
<br />All Faiths Funeral Home, 2929 S.
<br />
<br />
<br />
<br />16. PART I. Enter tha chain of p.venlsndiseases, Injuries, or compllcallons~"that direclly caused the death. 00 NOT enter lerminal avents such as cardiac arrest,
<br />rasplratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE, Enter only one cause on a line. Add additional lines If necessary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />1 onsello dealh
<br />1
<br />13
<br />
<br />---II--;';,el 10~ ')
<br />I
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In dealh)
<br />
<br />~_~n_(JVtA-c~.. Co.l'I.cc,~
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />
<br />Sequentially li.1 condition., if (b)
<br />any, leading to the cau.e 1I.led -DUE TO, OR AS A CONSEOUENCE '6F~
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(dl.ea.e or Injury Ihal inili'led (e)
<br />the evenl. r..ulllng In death)
<br />LAST
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I
<br />
<br />_."..,.~ _!_.-.
<br />I onset 10 dealh
<br />1
<br />1
<br />_-----.L ______
<br />I onset to death
<br />I
<br />I
<br />
<br />
<br />(d)
<br />18: PART II. OTHER SIGNIFICANT CONDITIONS-Condlll~~s e~;;;~lbUllng 10 Ih~dealh bUI not resulling in the Unde;IYin-~ cau.e glv~~-in P~~WAS-MEDICAL "XAMIN~
<br />I OR CORONER CONTACTED?
<br />__.-- ___~ ~ ONO
<br />20, IF FEMALE: 21e. MANNER OF DEATH 21b, IF TRANSPORTATION INJURY 21e. WAS AN AUTOPSY PERFORMED?
<br />o Nol pregnanl within pasl year U Natural 0 Homicide ODriver/Operalor 0 YES Ol.NO
<br />o Pregnant at time of dealh U AccidsnlD Pending Investigallon 0 Passenger . _.0 -- .----~-
<br />
<br />o Nol pregnant, bul pregnant wilhin 42 days 01 dealh 0 Suicide 0 Could nol be determined 0 pedestrian 21 d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />CI Not pregnant, bUI pregnanl43 days 10 1 year belore death 0 Olher (Specily) COMPLETE CAUSE OF D~ATH?
<br />o Unknown II pregnant within Ihe past year 0 YES \,l' NO
<br />
<br />22a, DATE OF INJURY (Mo, Day, Yr) t2b TIME OF INJUR: 22c. PLACE OF INJURY-AI h~~e, farm, str~~;, faclory, office-b~lldmg, con~~;;;cllon site elc-is~- -----
<br />
<br />22d_INJURYATWORK? -~ESCRIBEHO_WINJURYO_CCUR_R_ED - .--~
<br />o YES ONO J_
<br />-~,''''--'-'--'' .-.---'.--
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO_ CITYffOWN STATE ZIP CODE
<br />
<br />230. DATE OF DEATH (Mo" Day, Yr,)
<br />January 22, 2007
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr_)
<br />
<br />24b, TIME OF DEATH
<br />
<br />m
<br />
<br />~i:;
<br />,..- Z
<br />.oga::
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<br />c.n. i!( ~
<br />E "~ i: ~
<br />8ffiz
<br />..z::l
<br />"'00
<br />~a:U
<br />O~
<br /><>0
<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 Inv8stigallon, In my opinion death occurred at
<br />the lime, date and place and due to the cause(') staled. (Slgnalure and Tille) 'f
<br />
<br />260. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />o YES Ql,NO 0 PROBA Y 0 UNKNOv:'.~ _ 0 YE~___ll("NO. _ ___ ~_pp!lcable il 26a~' NO U YES 1Iil_~_
<br />V:NAM-E, TITLE AND AOPRESS RTiFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or prinl)
<br />Larry Hansen, M.D.,3016 W. Faidley Ave., Grand Island, Nebraska 68803
<br />
<br />28a_ REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b, DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />\\
<br />
<br />JAN 2 5 2001
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