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<br />200701247
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT J 1 ~ ~ 9 0
<br />Jt~RTIFICATE O_f_I2~ATH_'-r--~
<br />
<br />I. DECEDENT'S-NAME IFir...
<br />Lavern
<br />
<br />!,Iiddl..
<br />Donald
<br />
<br />LOll.
<br />Scarborough
<br />
<br />SUlli>,
<br />
<br />2 SEX
<br />Male
<br />
<br />3. DATE Of DEATH (Mo.. D.y. Vr.1
<br />October 11, 2005
<br />
<br />.. CITV AND STATE OR TERRITORY. OR fOREIGN COUNTRY OF BIRTH
<br />
<br />: 5'. AGE.L..I Blrlhday , 5b. UNDER 1 YEAR
<br />('Irs.) ~OS. OAYS
<br />i
<br />
<br />73
<br />
<br />Sc UNOER 1 OAY , B. OATE Of BIRTH (!,Io.. O.Y. vr )
<br />HOURS MINS 1
<br />October 13, 1931
<br />
<br />St. Paul. Nebraska
<br />
<br />8b. FACILITY-NAME (II nol ,nstilu"on. give ,Ireel .nd number)
<br />
<br />Be PLACE Of OEATH
<br />i~: ! Inp.ti.nl one 0 Nu",ng Hom",,-TC :J Ho'p,ce Fac'I"y
<br />~
<br />I
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />505-32-4045
<br />
<br />
<br />D EAlOutp.ti.nl 0 Oecedent's Hom'
<br />
<br />VA Medical Center
<br />
<br />DOOi\
<br />
<br />a Olhor (Si>oclfyl
<br />
<br />Be. CITY OR TOWN OF OEATH (Includ. Zip COll.1
<br />Omaha. NE 68105
<br />
<br />i 8<1 COUNTY OF OEATH
<br />! Douglas
<br />
<br />!lb. COl.NTY
<br />Hall
<br />
<br />90. CITY OR TOWN
<br />Grand Island
<br />
<br />10e. MARITAL STATUS ATTIME OF OEATH
<br />
<br />
<br />I ge. APT_ NO
<br />
<br />~
<br />
<br />lOb. NAME OF SPOUSE (Fill!. Middl.. L.... SuMi>) if wif., give m."'.n n.m..
<br />
<br />, 91. ZIP COOE
<br />! 68802
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />
<br />am 9
<br />f
<br />
<br />I
<br />Mickelson '
<br />Tab RELATIONSHIP TO -OECEDENT I
<br />+ Wife
<br />
<br />1'6C~~ .(M~,~'Y. Y;bos
<br />
<br />STATE
<br />
<br />Middle.
<br />
<br />Maiden Surn.m.,
<br />
<br />9d. STREET ANO NUMBER
<br />P.O Box 1526
<br />
<br />::J lAa"ied, but ..par.ted 0 WidPw.d 0 Oivorced 0 Unknown
<br />
<br />Theresa
<br />
<br />ke
<br />
<br />,1. FATHER'S.NAME (Fir..,
<br />Newman
<br />
<br />Middle.
<br />
<br />L..t,
<br />
<br />Suffl.)
<br />
<br />,12. MOTHER'S.NAME (Firsl,
<br />I
<br />I
<br />
<br />Sathena
<br />
<br />Oreo
<br />
<br />
<br />h
<br />
<br />13. EVER IN U.S. ARMEO FORCES? Give date, 01 serviC. il yes. I'..INFORMANT.NAME
<br />(Y...no.orunk.Kes 1/13/53_ - 1/12/55; Theresa Scarborou h
<br />
<br />ts.~:::~OFOI~::: II~R.SIG~~.~~. <- '6b;~;
<br />
<br />:lCremalion a Entombment i 16<1. CEMETERY. CREMATORY OR OTHER LOCATION CITY! TCWN
<br />
<br />:J Removal 0 OIher (gp.cify) I
<br />I
<br />
<br />Westlawn Memorial Park Crematory
<br />
<br />Grand Island
<br />
<br />17L FUNERAL HOME NAME "NO MAILING ADDRESS (Streel, City or Town. Statal
<br />Apfel Funeral Home 1123 West Second
<br />
<br />13- PART I. Enter the chaon ol....nts..dl......, injuri... or complicalions-.'Mat directly causea tho a.ath. 00 NOT enter termin.1 events sucM .. cardi.c s"..t.
<br />respireto,., arrest, or vonlricular tibrlllalion witllOu1'howing the etiology. 00 NOT ABBREVIATE. Enler only one cau.. on . Ii".. Add additional line. ~ n""....,.,.
<br />
<br />IIIIMEDtATE CAUSE: onMt 10 dooth
<br />
<br />!
<br />~
<br />i
<br />i
<br />I
<br />!
<br />
<br />(0) Cardiopulmonary Arrest 1 min
<br />DUE TO. OR AS A CONSEQUENCE OF: ' onset to dooth
<br />
<br />~1IoI---'. tb) Diabetes Mell itus Type 2
<br />any,-..glotho....._ ~UE TO, ORAS A CONSEQUeNCe OF: onsetlodealh
<br />on .... L
<br />EnIor..I.NlEALDIO CM.ISIi
<br />(_OI'~iiliclnllloiod '(0) Small Bowel Obstruction ' -7 days
<br />.. - rooulting.. cloolhl DUE TO. OR AS A CONSEQUENCE OF: , onsatlo death
<br />lJISl'
<br />
<br />(e!)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS.Condilloos conlflbutinglo the de.th bul nol resulting ,n IMe underlying causo given ,n PART J.
<br />
<br />19. WAS MEOICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />o VES XI NO
<br />
<br />20. IF fEMALE:
<br /><!II NOI pregnant wlth,n past yoar
<br />a Pregnaot at tim. of doath
<br />o Nol pregnant. but prog",nt wIIMin a2 dsys of d..tM
<br />:J No. pregnant. I)uI pregnanl-13 doY' 10 1 year betore do.th
<br />a Unknown if pregoaol wlth,n tho past year
<br />
<br />----I ~,.. MANNER OF OEATH
<br />I XI N.tura' 0 Hemic"'"
<br />
<br />II 0 "cclllenla p.nding Inveollgo'ion
<br />
<br />a Suic"," tl Could not be detarm'ned
<br />
<br />'121 b. IF TRANSPORTATION INJURY
<br />a OrlvarlOperator
<br />
<br />U P....nger
<br />
<br />o P_S"iOn
<br />
<br />a OIher (Specify)
<br />
<br />I
<br />I
<br />I
<br />1
<br />I
<br />~-~
<br />I 21d. weREAUTOPSY FINOINGS AVAILABLE TO I
<br />i COMPlETE CAUSE OF DEATH? I
<br />i a YES 0 NO ,
<br />I
<br />i
<br />i
<br />I
<br />---I
<br />
<br />,
<br />
<br />a YES
<br />
<br />XXNO
<br />
<br />2'c. WAS AN AUTOPSY PERFORMED?
<br />
<br />o YES ONO
<br />
<br />
<br />22c. PLACE Of INJURY.At Mome. larm. slreel. faclory. ottic. bu,lding. cons"ucllOn sile. ale. (SpeClty)
<br />
<br />22.. OATE OF INJURY IMo., D.y, Yr.)
<br />
<br />221_ LOCATION OF lti,/UAY . STREET & NUlllBER, APT. NO.
<br />
<br />ClTYII'OVttl
<br />
<br />SWE
<br />
<br />Z1PCOOE
<br />
<br />230. OATE OF DEATH (Mp.. Day. 'I,.)
<br />OcjQber_ 11: , 2005
<br />23b. DATE SIGNEO (Mo.. 0.'1. Yr_)
<br />October 11 2005
<br />
<br />2.a. DATE SIGNEO (1110.. O.y, Yr.)
<br />
<br />2~. TIME OF DEATH
<br />
<br />am
<br />
<br />I~~I
<br />II~i!
<br />~I~
<br />
<br />m
<br />
<br />210. PRONOUNCEO OEAD (Me.. Day, Yr,l t 24<1. ~DUO
<br />I m
<br />
<br />24e. On the besis of eurnlnation and/or investigation. in my optnKKl ljeath occurred at
<br />the tim.. dalO and plec. and due '0 the cause!s) ...Ieel. (Sigoature .nd Title) "
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />'j' 0:
<br />) .
<br />
<br />III NO
<br />OR COUNTY ATTORNEY) (Type or P,inl)
<br />, 4101 Woolworth AVe.
<br />---' '
<br />I
<br />i
<br />,
<br />I
<br />
<br />Not "pplic.bl. ,f 260 "NO 0 VO :J NO
<br />
<br />Omaha, NE 68105
<br />
<br />28b. OATE FILED BY REGiSTRAR (1110. Oay. Yr.)
<br />
<br />,(tll .\ 1>>ns~
<br />
<br />I . "'..!'l L \: .
<br />.I'! .. I" .
<br />l, g"" _, ~ ,.'" ..:'
<br />
<br />This certifies this do~u,m~l)tio be.a. trJJO't:~ ~fan original record on file with Vital Statistics, Douglas County
<br />Health Dept., Omaha, Neb~)ocnrtified ~opies must have a raised seal in the area to the left. Reproductions
<br />of this green certificate are 'not, legalc.opie's. . .'
<br />
<br />Date Issued:
<br />
<br />mT 1 4 2005
<br />
<br />Registrar:
<br />
<br />A ,.---~._---
<br />n~, .-
<br />.. ~ -.;1- C LHf
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