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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AIVPi;jJJMAN SERfllcES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGIN.MiRECtiRifON1=ILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL' STA!ffftJC$'~t;it~J"W#ICH, IS
<br />
<br />:::;::~~:::::~TORY FOR VITAL RECORDS. ~J*:'J:(f/if/~
<br />
<br />\:1B 2 IOO} If{'''r'''fltr4.1Ji;Ey S.COOPER
<br />. 'l 'e. , 2 0 0 7 0 1.9 3 3 MSIST4.N'fSt.A7JtfiEiilStilAR
<br />LINCOLN, NEBRASKA H~LTi1-A~D,,!~N:SERVlcES
<br />
<br />
<br />STATE OF NEBRASKA-DEPARTMENT OF HEALTH. AND HUM.A. N SERVICES FINANCEA. NDSUPP~'-7 I") I") ri ., t::
<br />..,.___n. CERTIFICA~E OF qEATH .__llL.LJ.:.j"J--L. ::>
<br />1. DECEDENT'S.NAME (FirS!, Middlo, LaGI, Sulfi.) 2. SEX 3. DATE OF DEATH (Mo.. Day, Yr.)
<br />James George McClaren Male February 12, 2007
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE.Last Blrlhd.y 5b. UNDER 1 YEAR
<br />(Y,".) MOS. DAYS
<br />69
<br />
<br />5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />HOuii'j MINS.. December 24,1937
<br />
<br />8a. PLACE OF DEATH
<br />~: 0 Inpalionl
<br />
<br />QlJ:JEB: a[ NUflllng Horne/LTC LJ Ho.pICO Faeilily
<br />
<br />8b. FACILITY. NAME (If nol In.lllullon, glva .treal and number)
<br />
<br />IJ ER/Oulpallonl
<br />
<br />IJ Docadenl" Home
<br />
<br />Francis Skilled Care Nursing
<br />
<br />Orol
<br />
<br />o Olher (Spoclfyl
<br />
<br />lOa. MARITAL STATUS ATTIME OF DEATH a[Merrlod 0 Never Marriad
<br />
<br />8d, COUNTY OF DEATH
<br />Hall
<br />
<br />. ~CITYORTOWN
<br />1 Grand Is~and
<br />-~~ 91, liP CODE -TIg.INSIDECITYLlMii-s
<br />68801 K YES 0 NO
<br />-..----'", .._.~.~-
<br />lOb. NAME OF SPOUSE (Fir.t, MloOlo, La.I, Sullix) If wite, give maldon name.
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Codo)
<br />Grand Island, 68803
<br />
<br />ge. RESIDENCE.STATE ~ 9b COUNTY
<br />~~ Hall
<br />-------~
<br />go. STREET AND NUMBER
<br />330 Pheasant DR
<br />
<br />o Divorced 0 Unknown
<br />
<br />Margaret Malone
<br />
<br />Mlddlo,
<br />
<br />La.t, Sulflx)
<br />McClaren
<br />
<br />12. MOTHER'S.NAME (Flrsl,
<br />Rose
<br />
<br />Middle,
<br />
<br />Malden Surnamo)
<br />Petersen
<br />
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />16c. DATE (Mo., Day, Yr.)
<br />Feb 17, 2007
<br />
<br />CITY /TOWN
<br />
<br />STATE
<br />
<br />Grand Island
<br />
<br />NE
<br />
<br />PART I. Enler Ihe cttJ\luol.mnll..di......, Injurio., or complleallons.-Ihat dlreelly caused Iho doath. DO NOT anter termlnale.enls .ueh as Gardlac arrasl,
<br />resplralory arro'l, or vanlrlculer t1brlllalion wilhoUlshowing Ihc ellology. DO Nor ABBREVIATE. Enler only ono cau.e on a line. Add addillonalllna.1f neGe..ary.
<br />IMMEDIATE CAUSE:
<br />
<br />Soquentlally Ust condltlono, if
<br />any, leading 10 the oau..Uat.d
<br />onlln811.
<br />Enterthe UNDERLYING CAUSE
<br />(dla..a. or Injury Ih.t InlllOloO
<br />thO ovenla ,",ullingln d..t~)
<br />lA5r
<br />
<br />(b) f (.,{ ':!,^MArL 'f
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Hyt..Ur~5 ro.--U
<br />
<br /> onse11o death
<br />I _ .'t II "-.S
<br />I
<br />I on.at to dealh
<br />I
<br />I .J Y,( 5
<br />I
<br />I onsel to d.alh
<br />
<br />IMMEDIATE CAUSE (Flna'
<br />dl..... or condition ,..ulUng
<br />10 dooth)
<br />
<br />(a) rt.. f 'SI'I~ Y
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />rA(~u".{L-.
<br />
<br />(c)
<br />. DUETO, OR AS A CONSEQUENCE OF:
<br />
<br />o AecldontO Pending Invo.llgalfon
<br />o Sulcldo IJ Could nol be dalormlned
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />o Drlver/Oporator
<br />
<br />o pa..onger
<br />
<br />o Pede,irlan
<br />
<br />o Olhor {Specily)
<br />
<br />____..J._.-.,
<br />I onscllo death
<br />
<br />I
<br />
<br />I
<br />
<br />
<br />] '". .., "''''''''~'",.----
<br />
<br />OR CORONER CONTACTED?
<br />
<br />o YES jl( NO
<br />
<br />~__.' "._,n"'__
<br />21e, WAS AN AUTOPSY PERFORMED?
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS.Condlllon. conlrlbuling 10 Ihe doalh but nol ro,ultlng In the underlying GaU.a given in PART I.
<br />
<br />_, e H/Eh..ollJ
<br />20. IF FEMALE:
<br />CJ NOI pragnanl wllhin pasl year
<br />o Pregnenlet limo of death
<br />o Nol prognanl, bul pregnenl within 42 day. 01 doath
<br />Cl Nol prognanl, but pregnanl43 day. 10 1 yoer belore doath
<br />o Unkno~n If prognanl wllhln the posl year
<br />
<br />210. MANNER OF DEATH
<br />KNotu,el U Homlcido
<br />
<br />'NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />o YES
<br />
<br />COMPLETE CAUSE OF DEATH?
<br />o YES 0 NO
<br />
<br />22d.INJURY AT WORK?
<br />o ygs 0 NO
<br />
<br />
<br />m
<br />
<br />22e. DATE OF INJURY (Mo., Doy, Yr,)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY.AI home, farm, streel, laGtory, offiGe building, con.Irucllon slle, stG. (Specify)
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />S1l\TE
<br />
<br />ZIP CODE
<br />
<br />2'0, DATE OF DEATH {M".. "oy, Y.!l
<br />;( -\Q. ... ..<.Oc.:Y I
<br />
<br />~4.. UME SIGNED (Mo., Day, Yr.)
<br />
<br />24b. liME OF DEATH
<br />
<br />:z>
<br />>- 00: w
<br />.t:I~Z
<br />i>2i
<br />-a.i!:~~
<br />E .~tZ
<br />8ffi:io
<br />"z'"
<br />"'00
<br />~~u
<br />o~
<br />U 0
<br />
<br />m
<br />
<br />24c. PRONOUNCED OEAD (Mo.. Day, Yr.) 24d, TIME PRONOUNCED DEAD
<br />'m
<br />
<br />24e. On the basis of examinalion and/or lnvestigallon, In my opinion dealh occurred al
<br />thellm~, dale and ploco and due 10 the ceu.e(.) 'Ialod. (SlgnalUre and Tille)"
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION aEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />
<br />r:l YES ~NO 0 PROBABLY 0 UNKNOWN 0 YES M NO N01 Appllcablaa 266 I. NO .0 YES Jl[ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER'"(PHYSICIAN, CORONER'S PHYSICIAN OiiCOUNTY ATTORNEY) (Type;;;p;j;;i)"
<br />David R. Colan MD 729 N. Custer AV, Grand Island, NE 68803
<br />
<br />28.. REGISTRAR'S SIGNATURE 28b. DATE FILED ay REGISTRAR IMo" Day, Yr.)
<br />
<br />
<br />FIB 2 ~j ZOll?
<br />
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