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<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECDRITONcFlLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlST/~1iC.Tg)N;JNii~H IS
<br />
<br />:::;::~~:::::;TORY FOR VITAL RECORDS'IY4J~::'w.~co~:-:~~=
<br />JUL 1 4 2005 2 0 0 7 0 2115 ""7~~T~f.!i;;tyoS.COOP~-'3
<br />AssisTANT S-TATE-MGJSTRAR~~
<br />LINCOLN, NEBRASKA HEAdi{ANQ__H~,,!A,!=-~ER}!idE~:
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />CERTIFICATE OF DEATH
<br />
<br />07465
<br />
<br />1. DECEDENT'S-NAME (Flrsl,
<br />Robert
<br />
<br />Middl.,
<br />
<br />Lasl,
<br />McWhirter
<br />
<br />Suffix)
<br />
<br />2, SEX
<br />
<br />Male
<br />
<br />5c, UNDER 1 DAY
<br />"HOURs-I-MINS.
<br />
<br />3, DATE OF DEATH (MD., Day. Yr.)
<br />Jul 2, 2005
<br />
<br />6. DATE OF BIRTH (Mo.. D.y, Yr.)
<br />
<br />J.
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Adams County, Nebraska
<br />
<br />5a. AGE.LaslBlrthday
<br />(Yrs.)
<br />79
<br />
<br />5b. UNDER 1 YEAR
<br />-"XOS:I:YS
<br />
<br />
<br />--.-- '-~
<br />Ba. PLACE OF DEATH
<br />
<br />May 24, 1926
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />508-30-2667
<br />
<br />~:
<br />
<br />IJIlnpall.nl
<br />
<br />QlliE8; CJ Nursing Home/LTC CJ Ho'plce Feclllly
<br />
<br />Bb.JP'CILJTY.NAME (II not In,tII.1Hlo", Ojve Slc.el .nd number)
<br />Mary Lanning Memorial Hospital
<br />
<br />- ---- - -CJ ER/Oulpellenl
<br />
<br />o Decedent's Home
<br />
<br />OOCl'l
<br />
<br />CJ Olh.r(Speclly)__________
<br />
<br />6c. CITY OR TOWN OF DEATH (Includa Zip Coda)
<br />
<br />Has t~.l1gs
<br />ga. RESIDENCE-STATE
<br />Nebraska
<br />
<br />68901
<br />
<br />Bd, COUNTY OF DEATH
<br />Adams
<br />
<br />I 9b, COUNTY
<br />
<br />Hall
<br />
<br />
<br />9d. STREET AND NUMBER 91. ZIP CODE
<br />367 West Rosedale Road 68832
<br />lOa. MARITAL STATUS""AT TlMEOF'j)-WH-\5 Marrl.d 0 Never Married lab. NAME OF SPOUSE (Flrsl, Middla, Last, Sullix) II wita, give maiden nama.
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />CJ YES W NO
<br />
<br />CJ Divorced CJ Unknown
<br />
<br />Darlene M. Arnold
<br />
<br />11. FATHER'S-NAME (First,
<br />Cliff
<br />
<br />Middle,
<br />
<br />Last, Suffix)
<br />McWhirter
<br />
<br />12. MOTHER'S-NAME (Flrsl,
<br />Grace
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />Markham
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dales 01 ,ervlce II yes. 14a.INFORMANT-NAME
<br />No Darlene McWhirter
<br />15. METHOD OF DISPOSITION
<br />ill Burial ODonallon
<br />CJ Cr.matlon 0 Enlombmenl
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Wife
<br />
<br />o R.moval U Olhar (Speclly)
<br />
<br />
<br />16b. LICENSE NO.
<br />1210
<br />
<br />CITY / TOWN
<br />
<br />16c. DATE (Mo., Day, Yr.)
<br />__ July ~,__ 2005
<br />
<br />STATE
<br />
<br />
<br />Trumbull
<br />
<br />122S-North Elm venue
<br />Hastings, Nebraska
<br />
<br />Nebraska
<br />
<br />PART I. Enl.r the chain ot ev.ntsudl,.as." InJurl.S, or compllc.tlons--Ihat directly caused Ihe death. DO NOT enler lermlnal events such as cardiac arresl,
<br />r.'plratory arr.st, or venlrlcular fibrillation wtlhoul ,howlng Ihe ellology. DO NOT ABBREVIATE. Enl.r only on. cause on a line. Add addilionallines II necessary.
<br />
<br />
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Slreel, Clly Dr Town. Sial e)
<br />
<br />Livingston-Butler-Volland Funeral Home
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />on,el to dealh
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />dl..... or condlllon ....ulllng
<br />In de'lh)
<br />
<br />(a) ~tM~~~ ~
<br />
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />onset to death
<br />
<br />Sequentl.lly IIsl conditions, II (b)
<br />.ny,le.dlnglolh.c.usoll.lod --DUE TO;'OR AS A CONSEQUENCE OF:
<br />on tine..
<br />, EnlorthoUNDERLYlNClCAUSE
<br />(dl..... or Injury Iho'lnllloled (c)
<br />Ihoovonls ro.ulllngln doath) ..- DUE TO, ORASACONSEQUENCE OF:
<br />lA'lT
<br />
<br />onsol to dealh
<br />
<br />oMello dealh
<br />
<br />(d)
<br />
<br />lB. PART II. OTHER SIGNIFICANT CONDITIONS-Condition, contributing to Ihe d.ath bul not resulllng In the underlying cau,e given In PART I.
<br />
<br />19, WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />CJ YES ~ NO
<br />
<br />20. IF FEMALE;
<br />
<br />21a. MANNER OF DEATH
<br />:& Nalural CJ Homlcld.
<br />
<br />CJ AccldenlCJ Pending Investigation
<br />
<br />21b. IF TRANSPORTATION INJURY
<br />CJ Drlver/Operalor
<br />
<br />CJ poss.nger
<br />
<br />CJ Pedestrian
<br />
<br />21c. WAS AN AUTOPSY PERFORMED'
<br />
<br />o Not pregnant within past year
<br />o Pregnanl al time 01 dealh
<br />
<br />CJ YES
<br />
<br />Xl NO
<br />
<br />CJ Not pregnant, but pregnanl wllhln 42 days of dealh CJ Suicide CJ Could nol be determined 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />CJ Not pregnant, bul pregnant 43 days to 1 year b.fore d.alh 0 Olher (SpecIIY) COMPLETE CAUSE OF DEATH?
<br />CJ Unknown It pregnant wllhin the past y.ar CJ YES CJ NO
<br />22a~~~:~;-I:iJ:~nY-i~t~~~~~) -]~~G_~I~:OF r;iJUR'~ 1_220' PLACE OF INJUHY-At hom., larm, we.l, loctory, ofllc. '""Idlng, construcllon sll., .Ic. (Sp.clfy)
<br />
<br />
<br />22d.INJURY AT WORK? 22.. D~SCRISE HOW INJURY OCCURRED
<br />
<br />o YES 0 NO
<br />
<br />22t. LOCATION Of INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CrrYlfOWN
<br />
<br />STArE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (MD., Dey, Yr.)
<br />.. J\l.~y},__200~
<br />
<br />24a. DATE SIGNED (MD., Day, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />am
<br />
<br />~~~
<br />1l~a:
<br />ji~~
<br />Q;.Q.-I:l::i
<br />Efh[:Z
<br />8ffizO
<br />llz=>
<br />,21i18
<br />85
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo.. Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of exarnlnallon and/or InvestIgation, In my opInIon death occurred al
<br />Ih. lim., data and plac. and due 10 Ihe cau,e(s) ,Ialed. (Signalure and Tille) 'I'
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />CJ YES CJ NO CJ PROBABLY NKNOWN CJ YES :lb NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICtAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type Dr Prlnl)
<br />Kevin K. W coff, M.D. 1021 W 14th St., PO Box 968
<br />2Ba. REGISTRAR'S SIGNATURE
<br />
<br />2Bb. WAS CONSENT GRANTED?
<br />
<br />Nol Applicable If 26e is NO CJ YE~~_~O
<br />
<br />Hastings, NE
<br />
<br />68902
<br />
<br />\
<br />
<br />
<br />2Bb. DATE FILED BY REGISTRAR (MD., Day, Yr.)
<br />
<br />JUL- 8 2005
<br />
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