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<br />200701716
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTJ:I-AIVOf<<JMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGtNAL.Bl!lfOIfDOitoF1LE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL s.riif~-f€'~~~'W.H)CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~~"e;"l
<br />
<br />
<br />;~; ~F ;;~~~CE .20060 8 ~ 2 7 ~ssm~:j.~~:~:
<br />LINCOLN, NEBRASKA H(~LTfjANi;},~ltN Sf,ftVICES
<br />
<br />STATE OF NEBRAsKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SIJPF'0Ffl16
<br />CERTIFICATE OF DEATH U
<br />---.... ... --,..__..~,-~~-_."'----"-,.""_....,.
<br />
<br />29709
<br />
<br />1. DECEDENT'S.NAME (First,
<br />Robert
<br />
<br />3. DATE OF DEATH (Mo" Day. Yr.)
<br />August 26, 2006
<br />
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />Middle,
<br />James
<br />
<br />Last,
<br />Johnson
<br />
<br />Suffix)
<br />
<br />2.SEX
<br />Male
<br />
<br />4. crry AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a. AGE.La,t Birthday
<br />(Yrs.)
<br />
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />Ayr, Nebraska
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />505-26-6489
<br />
<br />March 3, 1926
<br />
<br />80
<br />
<br />8a. PLACE OF DEATH
<br />1iilliElIAl.: ... Inpalient
<br />
<br />QllifB: \II:! Nursing Homa/LTC 0 Hospice Facility
<br />
<br />6b. FACILITY-NAME (If nol instllullon, give street and number)
<br />
<br />o ER/Outpallent
<br />
<br />o Decedonl's Home
<br />
<br />St. Francis Skilled Care
<br />
<br />6c. CITY OR TOWN OF OEATH (Include Zip Code)
<br />Grand Island 68803
<br />
<br />_.~__.____.~iSpooIM
<br />~~~_.". -~_.-
<br />6d. COUNTY OF DEATH
<br />Hall
<br />
<br />i':,",..,__
<br />
<br />. ,_..~~-,~,.,~........' -,--,~,...-...,~",..,
<br />
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />
<br />9d. STREET AND NUMBER
<br />1808 West Second
<br />
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />10 YES 0 NO
<br />
<br />9b. COUNTY
<br />Hall
<br />
<br />91. ZIP CODE
<br />68803
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH ~Married 0 Never Married lOb. NAME OF SPOUSE (First, Middle, Lae!. Sulllx) If wlf., give maiden oam..
<br />
<br />o Married, butseparat.d 0 Widowed 0 Divorced (J Unknown Mer leen Geisert
<br />
<br />11. FATHER'S-NAME (First,
<br />James
<br />
<br />12. MOTHER'S.NAME (First,
<br />Neva
<br />
<br />Malden Surname)
<br />Connely
<br />
<br />Middle,
<br />
<br />Middl.,
<br />P.
<br />
<br />Last,
<br />Johnson
<br />
<br />Suffix)
<br />
<br />13, EVER IN U.S. ARMED FORCES? Give dal.. of s.rvice if yes. 14a.INFORMANT.NAME
<br />(Yes,n~~6Il~.) 6-7-1944 5-19-1946 Merleen Johnson
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />15. METHOD OF DISPOSITION
<br />lXBurial 0 Donation
<br />
<br />16c. DATE (Mo.. Day, Yr.)
<br />
<br />Septe~ber 1,_ 2006__
<br />
<br />STATE
<br />
<br />16a. EMBALMER-SIGNATURE
<br />
<br />
<br />16d, CEMET~-~~'~O~~CATION
<br />
<br />16b, LICENSE NO.
<br />Ji' /~z.S-
<br />
<br />CITY / TOWN
<br />
<br />U Cramallon 0 Entombmanl
<br />U Removal U Othar (Spaclfy)
<br />
<br />Ayr,
<br />
<br />Nebraska
<br />
<br />Blue Valley Cemetery
<br />
<br />.,,'1
<br />
<br />, i
<br />
<br />
<br />17a. FUNERAL HOME NAME AND MAILING AODRESS (Street, City or Town, State)
<br />Apfel Funeral Horne,
<br />
<br />16. PART I. Enter Ihe ~~..nla--di'easea, InJuries, or compllcallons--Ihal dlreclly caus.d Ih. de.th. DO NOT .nl.r t.rmlnalavents such as cardiac arrest.
<br />respiratory arresl, or venlricular fibrillation without showing Ihe etiology. DO NOT ABBREVIATE, Enter only one oause on a line. Add additional lines if necessary.
<br />
<br />I
<br />I
<br />
<br />I onset to death
<br />I
<br />I
<br />I
<br />I
<br />I
<br />
<br />IMMEDIATE CAUSE;
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl..... or condition ,..ulllng
<br />In d..th)
<br />
<br />(a) MI7;\S7Anc. CJvuIN'aM-4
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />
<br />0/ /~S7t4[r
<br />
<br />_ _~. rt1I_._
<br />
<br />onset to death
<br />
<br />SoquonU.lly Itst condIUon., If (b)
<br />any, leading 10 the cause nsted DUE TO, OR AS A CONSEQUENCE OF:
<br />on line a,
<br />Entortho UNDERLYING CAUSE
<br />(dl,e.se 0' Injury Ihatlnltlated (e)
<br />theeven!s resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />lAST
<br />
<br />onsat 10 daalh
<br />
<br />onsallo daath
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS.Condltions cootribullng to Ihe death bUI not ,e,ulllng in the underlying cause glvan In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />DYES LJl40
<br />
<br />eJlr /IU}f,.{J
<br />
<br />20. IF FEMALE:
<br />o NOI pregnant wllhin paSI yea'
<br />o Pregnantaltime 01 death
<br />U Not pregnanl, but pregnanl within 42 days of d.ath
<br />o NOI pregnanl. but pregnant 43 days to 1 year belore death
<br />o Unknown If pr.gnanl within Ihe pasl ysar
<br />
<br />21b.IF TRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />o Passenger
<br />
<br />o P.destrlan
<br />
<br />I..J Other (Speclty)
<br />
<br />2td, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />21c, WAS AN AUTOPSY PERFORMED?
<br />
<br />2t a. MANNER OF DEATH
<br />~alUral 0 Homicide
<br />
<br />DYES
<br />
<br />~O
<br />
<br />o AccldenlD Pending Invesllgallon
<br />
<br />o Suicide 0 Could not be determined
<br />
<br />22a. DATE OF INJURY (Mo., Day, yr)_ _2~:_T~~:~:IN~U~~J22-;P~C~~~JURY:Ath~;;;~'-iarm, slr..t: iac;;;y, ofli~. building, construe lion sile, etc, (spe~,ty)---
<br />
<br />
<br />22d, INJURY AT WORK? 220. DESCRIBE HOW INJURY OCCURRED
<br />
<br />DYES 0 NO
<br />
<br />CInWN
<br />
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<br />8 I;
<br />
<br />I 24a. DATE SIGNED (Mo" tliy. Yr,,, .
<br />
<br />Mil. TIME OF DEATH
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24.. On Ihe basi. 01 e..mlnallon and/or investigation, In my opinion death occurred al
<br />Ihe time, date and plac. and due to the cause(.) slafed. (Signature and Title) ...
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />".__9__~g~.O___9~~()B_~~~'C.--.9_ UNKNOWN 0 YES 0
<br />27. NAME. TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNT ATTORNEY) (Type 0' Prlnl)
<br />David Colan M.D. 729 N. Custer, Grand Island, NE.
<br />
<br />Nol Applicable If 26a Is NO U YES
<br />
<br />NO
<br />
<br />68803
<br />
<br />
<br />28bSEpIL.ED B7 RZOOR6\(MO., Day, Yr,)
<br />
<br />"A"
<br />
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