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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HLlMANSERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL..BECOIMMJ~.;...F1Lfi1N1rH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIStiCS SEcm:iN;~/bl+-'$
<br />
<br />:::;::~::::::;TORY FOR VITAL RECORDS. I..:: ~<;~h-:~':.--~- J'~..-~;:.=~~ '
<br />"'f~'''' fJtANtEW's. (j~~R
<br />JAN 1 2 2007 J!$$$TANT=$'rAttliEQ&TtjAFt
<br />LlNCOLN,NEBRASKA 200'70Uh8 H\J!1~7:E!S
<br />
<br />
<br />
<br />STATE OF NEBRASKA ~ DEPARTMENT OF HEALTH AND HUMAN SERVICES FI~ANCE AND'SUPPOFp:., 63 . 4 5 9 3
<br />_ CERTIFICATE Of DEATH ~ .. -.U___
<br />
<br />1, DECEDENTS.NAME (Flrsl,
<br />John Edward
<br />
<br />Middle, Lest.
<br />DeBaoker
<br />
<br />Suffix)
<br />
<br />2, SEX
<br />Male
<br />
<br />3, DATE OF DEATH (Mo., Day, Yr.)
<br />Deoember 31, 2006
<br />
<br />~. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa, AGE-Last Sirthday
<br />IY'",)
<br />
<br />5b. UNDER 1 YEAR 5c, UNDER I DAY
<br />MOSJ, DAYS I HOURS l"~iNS'
<br />
<br />
<br />8a. PLACE OF DEATH
<br />
<br />6. DATE OF BIRTH IMo" Day, Yr.)
<br />
<br />"
<br />
<br />Omaha, Nebraska
<br />
<br />50
<br />
<br />February 3, 1956
<br />
<br />., .~
<br />
<br />7, SOCIAL SECURITY NUMSER
<br />506-68-1462
<br />
<br />.HOSPITAL:
<br />
<br />U Inpalionl
<br />
<br />Q1I:JEB: Cl Nursing Homo/LTC Cl Hospice Facility
<br />
<br />Bb. FACILITY-NAME (If not Instllution, givo slreel and number)
<br />
<br />Cl ERlOutpalionl
<br />
<br />)Q. Decedent's Home
<br />
<br />2009 W Division St.
<br />
<br />9a. RESIDENCE-STATE
<br />
<br />Nebraska
<br />
<br />9d. STREET AND NUMSEn
<br />2009 W Division St.
<br />
<br />19b. '.COUNTY
<br />Hall
<br />
<br />o CO\ 0 Olher (Specify)
<br />
<br />rd-' CO;~;~ DEATH
<br />t~I=O~TOWNG=~~'d -~slanci_..
<br />
<br />ge, APT, NO 9f. ZIP CODE
<br />68803
<br />
<br />
<br />99. INSIDE CITY LIMITS
<br />'XI YES 0 NO
<br />
<br />Be. CITY OR,TOWN OF DEATH (Include Zip Code)
<br />
<br />Grand Island 68803
<br />
<br />10a, MARITAL STATUS ATTIME OF DEATH ClI Married 0 Nover Marriod lOb, NAME OF SPOUSE (First, Middlo, Lasl, Sulfix) If wife, give maiden namo.
<br />
<br />o Married, bul separatod 0 Widowed U Divorced 0 Unknown Donna Rose Welch
<br />
<br />11, FATHER'S-NAME (First, Middlo,
<br />Richard Lionel DeBaoker
<br />
<br />LeSI,
<br />
<br />SulfiX)
<br />
<br />12. MOTHER'S-NAME (First, Middle,
<br />Patrioia Maureen Lynch
<br />
<br />Maiden Surname)
<br />
<br />OSurial
<br />
<br />o Donetlon
<br />
<br />14a,INFORMANT.NAME
<br />Donna R. DeBaoker
<br />
<br />16e, EMr~:R:IG=:lmed .__~ 16b lICENS:NO_...
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />(Yes, no, or unk.)
<br />
<br />13, EVER IN U,S, ARMED FORCES? Givo dales 01 service II yes,
<br />NO
<br />
<br />aCromallOn 0 Entombmenl
<br />
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY /TOWN
<br />
<br />16c. DATE (Mo., Day, Yr,)
<br />January 1, 2007
<br />
<br />STATE
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />o Removal
<br />
<br />o Olher (Specify) Central Nebraska ~remation Service, Gibbo~, Nebraska
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Sir eel, Clly orTown, Slalo)
<br />, Kleine Funeral Home, 3213 W No~th Front
<br />:;fi :i1~f: "'. n... - n..n,_._,,_.
<br />1B. PART I. Enler the choln ot ovents--disoases, Injuries, or complicalion,nthal diroctly caused Ihe death, DO NOT ontor lorminal evenl. such es cardiac arrest,
<br />respiratory arrest! or ventricular fibrlllallon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additionallin8s if necessary.
<br />
<br />
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onset to dealh
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition re8ulting
<br />In deelh)
<br />
<br />, 0/
<br />(a) ~ . 4~-.: ..h//<'//'r
<br />DUE TO, O~ AS "CONSEQUENCE OF:' /
<br />/ 7' ,1 .
<br />(b) 7. :e1fZ!cj~t!:J C!. /-0:~___
<br />
<br />DUE Tb, OR A"VCONSEQUENCE OF: ( ~
<br />
<br />I
<br />I
<br />L(..LLtY'I -<J
<br />J,/ onsello deeth
<br />I
<br />
<br />: Q~:1_
<br />
<br />I
<br />I
<br />I
<br />
<br />Sequenlially Ilsl conditions, If
<br />any, leading to the caU9E1liated
<br />on line B.
<br />Enter Ihe UNDERLYING CAUSE
<br />(dlseose or Injury Ihallnlllaled
<br />Ihe evenlS ,esulllng In dealh)
<br />LAS1'
<br />
<br />(e)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />oMelia death
<br />
<br />(d)
<br />
<br />o Not pregnanl wlll1in pest year
<br />U Pregnant at lime of death
<br />o Nol prognanl, but pregnant wilhin 42 days of dealh
<br />o Not pregnant, bul pregnanl43 dayalo 1 year bolore doath
<br />U Unknown iI pregnant within the past year
<br />2;; DATE-OF'INJURY (Mo" Day, Yr,) . [22b' TIME OF I~JUR:
<br />
<br />
<br />22d. iNJUny AT WORK? 22e, DESCRIaE HOW INJURY OCCURRED
<br />
<br />o AccidentO Ponding Invosllgallon
<br />
<br />21 b.IFTRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />o pa..ongor
<br />
<br />Q Pedestrian
<br />
<br />U 0111er (Speclly)
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORQNERCONT9D?
<br />DYES p-rfo
<br />
<br />21c, WAS AN AUTOPSY PER~ED1
<br />
<br />DYES i94'
<br />
<br />18, PART II, OTHER SIGNIFICANT CONDITIONS-Condition, contribuling 10 tile death bUI not ,e.ulting in tho undorlying causa 91ven in PART I.
<br />
<br />20. IF FEMALE:
<br />
<br />21a. MANNER OF DEATH
<br />131ialural 0 Homicide
<br />
<br />o Suicide 0 Could nol ba determined
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />_._~-"...- I.
<br />220. PLACE OF INJURY-At home, farm, stre",t, factory, office bulldlng, construction site, etc. (Specify)
<br />
<br />COMPLETE CAUSE OF DEATH?
<br />U YES 0 NO
<br />
<br />o YES 0 NO
<br />
<br />22f.LOCATlON OF INJUny " STREET & NUMBER, APT, NO.
<br />
<br />CITyrrOWN
<br />
<br />SWE
<br />
<br />ZIP CODE
<br />
<br />
<br />230, DATE OF ~~o'" Da;'y1
<br />_~__L:...? -eLL 0.. 6~m
<br />23b, DATE SIGNED (Mo., Day, Yr.)
<br />/j;).. 3" . (,.
<br />
<br />24e, DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />!'~~
<br />a:mr5
<br />iH
<br />~n. ~ ~
<br />5"'1:Z
<br />uffizO
<br />~z"
<br />~~8
<br />'....0 I..
<br />C)o
<br />
<br />m
<br />
<br />24c, PRONOUNCED DEAD (Mo" Day, Yr.) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. an the basis of examination and/or Investigation, in my opinion death occurred at
<br />tho lime, date and place and duo to tho cause(s) Slated, (Signature and Tille) '"
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION SEEN CONSIDERED?
<br />
<br />26b, WAS CONSENT GRANTED?
<br />Nol Applicable if 2B..~.i~..~O 0 YES ~
<br />
<br />2Ba. REGISTRAR'S SIGNATURE
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />~
<br />
<br />rJAN 1 () 2007
<br />
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