|
<br />WHEN THIS COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMA~';~~~~
<br />SYSTEM, IT CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORij'oN'i=ttE wltH:'~'.
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA TI~TI~SECTIbN:l!fIiCJ#IS1;i'r.
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~'.:;-_'O;,,-~., =-'1,.fI.::.L:-:~,')f .'.
<br />DA TE OF ISSUANCE _. ' _ p. '.: LfVOt~~\~:.
<br />8/10/2004 2007018 31 A;SISrANT":rt::~~g~~
<br />LINCOLN, NEBRASKA HEAL TH AND-HUMAN SlEIiylc;es $'fST~M
<br />
<br />STAlE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />
<br />04
<br />
<br />08589
<br />
<br />1. DECEDENT - NAMI;
<br />I
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />2, SEX 3, DATE OF DEATH (Monlh. Day. Yea,)
<br />
<br />Helen
<br />
<br />wi1hemena
<br />
<br />Johnson
<br />
<br />St. Libory, Nebraska
<br />7. SOCIAL SECURTlY NUMBER
<br />
<br />5., AGE - La.t Birthday
<br />(Y".I 90
<br />
<br />UNOI,R 1 YEAR
<br />5b. MOS, DAYS
<br />
<br />Female July 31, 2004
<br />UNDER 1 DAY 6, DATE OF BIRTH IMonlh, Day, Year)
<br />5e, HOURS' MINS.
<br />
<br />March 19, 1914
<br />
<br />4, CITY AND STATE OF BIRTH II/nolin U.S.A.. nama CQunlryl
<br />
<br />8b. FACILIty - Name
<br />
<br />(II not institution, give st"eet and numbBrJ
<br />
<br />a.. PLACE OF DEATH
<br />HOSPITAL: D
<br />D
<br />D
<br />
<br />Inpatient OTHER: [j] Nursing Hom@
<br />ER Outpatient D Residence
<br />DOA D O1her (Sp8CltVI
<br />
<br />507-64-8279
<br />
<br />wedgewood Care Center
<br />
<br />ae. CITY. TOWN OR LOCATION OF DEATH
<br />
<br />16, FATHER.. NAME
<br />
<br />FIRST
<br />
<br />
<br />ad, INSIDE CITY LIMITS
<br />Y.. Ii] No
<br />CITY, TOWN OR LOCATION
<br />
<br />COUNTY OF DEATH
<br />
<br />Grand Island
<br />
<br />Hall
<br />STREET AND NUMBER (Including Zip Codel
<br />
<br />ge. INSIDE CITY LIMITS
<br />
<br />9a. RESIDENCE. STATE
<br />
<br />------r CO;:n
<br />
<br />10. RACE - (e.g., While, Bla!::k. Amerioan Indlan~-.-1'1-1~ .ANCESTRY le,g,
<br />atc,IISpoc'fyl whi te {SpoC'1vI Ameri can
<br />
<br />...-.-.----..
<br />14a. USUAL OCCUPATION (Give kind of work oon8 during most
<br />of warlo(,g life, even il retired,
<br />Food Service
<br />
<br />Nebraska
<br />
<br />68801 Yo, [ij NO D
<br />13, NAME OF SPOUSE (II wifB. giVB maidfln nam8)
<br />
<br />MIDDLE
<br />
<br />Hospital
<br />LAST
<br />
<br />
<br />(SpeCify only highest grade completedl
<br />Elementary or Secondary /0.121 College (1-4 or 5"'\
<br />8
<br />
<br />H. MOTHER
<br />
<br />MIDDLE
<br />
<br />MAIDEN SURNAME
<br />
<br />Herman
<br />
<br />18. WAS DECEASED EVER IN U,S. ARMED FORCES?
<br />(Yes. no. or unk.l (If ye$. give war and dales of MIIrvicBS)
<br />No
<br />
<br />Ruge
<br />
<br />Anna
<br />
<br />Schwenk
<br />
<br />1 ab. INFORMANT
<br />
<br />MAILING ADDRESS
<br />
<br />Wilbur Johnson
<br />ISTREET OR R.F,D, NO" CITY OR TOWN. STATE. ZIP)
<br />
<br />
<br />Island, Nebraska
<br />
<br />68801
<br />
<br />20.
<br />
<br />21 a, METHOD OF DISPOSITION 21 b. DATE
<br />
<br />210, CEMETERY OR CREMATORY NAME
<br />
<br />H07l
<br />
<br />00 Burial D Removal 5, 2004 westlam. MatPrial Pal:k
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN
<br />
<br />STATE
<br />
<br />D Cremalion D Donation
<br />
<br />Grand Island, Nebraska
<br />
<br />22b, FUNERAL HOME ADDREss
<br />
<br />._.____...___._..u. _..
<br />{STREET"ORR,f,D, NO.. CITY OR TOWN. STATE. ZIPI
<br />
<br />2929 S. Locust st~, Grand Island, Nebraska
<br />
<br />68801
<br />
<br />n IMMEDIATE CAUSE
<br />PART C .
<br />'Ial MliLA"'~)'U.Lr.{,J~
<br />
<br />OUE TO, OR AS A CONSEOUENCE OF,
<br />
<br />(ENTER ONLY ONE CAUSE PER LINE FOR lal. Ibl, AND {ell
<br />
<br />I Interval between onset <:1M dealh
<br />I
<br />I
<br />I
<br />I Inte(val between onset and deatn
<br />I
<br />: 5~(JJ~
<br />
<br />! InIElr...ci.i MtwUEln onset .and ::'leam
<br />I
<br />I
<br />I
<br />25 WAS CASE REFERR"D TO MEDICAL
<br />EXAMINI;R OR CORONER?
<br />
<br />,Jlv\.h;('
<br />
<br />(bl
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />
<br />"il,.~
<br />
<br />Icl
<br />
<br />PA~r OTHER SIGNIFICANT COND'TION~. Conditions contributing to the death but not related
<br />
<br />II l:h',J' 0 S.\..wf."Yl:> )to.> i
<br />I
<br />
<br />: 26a.
<br />
<br />26b. OATE OF INJURY 1M<>" Oay, Yr,) 260. HOUR OF INJURY
<br />
<br />
<br />26g. LOCATION
<br />
<br />STREET OR R,F,D. NO.
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />iD
<br />'0
<br />I
<br />o
<br />
<br />Accident D Undetermined
<br />Suicide D Pending
<br />
<br />Homicide
<br />
<br />Investigation
<br />
<br />26e, INJURY AT WOR~
<br />Y., D NO D
<br />
<br />27'. DATE Of DEATH IMo.. Day. Yt)
<br />
<br />28a. DATE SIGNED IMo" Day, Yt.I
<br />
<br />2Bb TIME OF DEATH
<br />
<br />July 31,
<br />
<br />2004
<br />
<br />27d. To the best of my knowledge. death occurrod at the time, date and place and due to the
<br />C211se(Sf slalsd.
<br />
<br />~ "1.. ~
<br />
<br />289. On the basis of examination and/or investigation. in my opinion death occurred i:lt
<br />the time. date and place and due 10 the c:ausels) :stated.
<br />
<br />~ (Si nature and Title) ...
<br />31).' HAS ORGAN OR TISSUE DONATION BEI;N CONSIDERED? 30,b WAS CONSENT GRANTED?
<br />
<br />D YES ~NO DYES. MNO
<br />
<br />$~~
<br />~~~
<br />if. e >-
<br />8"'t~
<br />llffi!
<br />0150
<br />>-i3"
<br />" ~
<br />
<br />M
<br />
<br />.Ei'~
<br />~ ~ ~
<br />-~>-;.-
<br />:. !~g
<br />1l~
<br />0"
<br />>--
<br />
<br />27b. DATE SIGN EO (Ma.. Day. Yr.)
<br />
<br />27e. TIME OF DEATH
<br />
<br />2Bc. PRONOUNCED OEAD (Mo.. Day, Yr.1
<br />
<br />28d. ~RONOUNCED DEAD (Houri
<br />
<br />fj - S -0 tj
<br />
<br />11:20
<br />
<br />P. M
<br />
<br />M
<br />
<br />[Si n.ature and Tille) ...
<br />29, DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />D YES ~ NO D UNKNOWN
<br />
<br />31. NAME AND ADDRESS Of CERTIFIER {PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI (Typo or Print/
<br />
<br />Anne K. Morse M.D.
<br />32.. REGISTRAR
<br />
<br />
<br />DATE FILED BY REGISTRAR IMo.. Day. Yr./
<br />
<br />AUG 9 2004
<br />
|