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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAN SERVICES
<br />SYS1E'M, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL REc;~D _pN FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlST!~~Sf.C,1Jf!N,~wtlICH IS
<br />
<br />:::~::~:::::~TORY FOR VITAL RECORDS. ~~. ~::~->::-~-'J -~~
<br />SEP 13 2004 200703215 ~NLEYS.COOPI!R
<br />ASSISrAN>>MrAJis9IS1R4R
<br />LINCOLN, NEBRASKA HEAL TH ANO:HUMAffsERWCES SyBt';M
<br />
<br />" OoCoOoNT - NAME
<br />
<br />'"' =3;-.==.'~:::-==':- . =~~.
<br />STATE OFNEBRASKA~ DEPARTMENT OF=~A~TI~ SER\"l~~g?~~urPbRT
<br />CERTIFICATEOFDEATH'" -- '_c_~ <.- 04 09848
<br />
<br />FIRST MIOOLo LAST 2, SoX J, OATI:: OF OI::ATH (Month. oa.. y..,)
<br />
<br />Sandra
<br />
<br />Jean Thompson
<br />
<br />Sa_ AGE, Last Binhday UNOER 1 YI::AR
<br />IY,,-' 6 2 50. MOS_ OA YS
<br />
<br />8a. PLACE OF OI::ATH
<br />
<br />HOS~ITAl 0 Inpa'iont
<br />
<br />D ER Outpliltient
<br />
<br />o OOA
<br />
<br />~ August 19, 2004
<br />
<br />UNOER 1 OAY 8. OATI:: OF elRTH IMonfh.Oay. Y.ar)
<br />5c, HOURS' MINS,
<br />
<br />August 12, 1942
<br />
<br />4, Cl1V ANO STATE. OF 81Fl1H III t1atin U.S.A.. flame country}
<br />
<br />Keokuk, IA
<br />-7: SOCIAL SoCURTIY NUMBoR
<br />
<br />479-50-9890
<br />
<br />OTHER: 0 NurSing Home
<br />
<br />~ Fl.e!:ildence
<br />
<br />o Otner (Speedv!
<br />
<br />8b. FACIU1v - Name (If not ;flstitution, give sfreflt Cind l1UmbM)
<br />
<br />#7 Kuester Lake
<br />Bc. CITY. TOWN OR LOCATION OF OEATH
<br />
<br />white
<br />
<br />Grand
<br />11. ANCESTRY (e.g. Italian. Mexican, German, ete)
<br />
<br />ISpeclfy! Ameri can
<br />
<br />
<br />STREI::T ANO NUMBER (Including Zip Cod'l
<br />Kuester 6~e
<br />
<br />9B, IN SlOE CITY LIMITS
<br />
<br />ad_ INSIDE CITY LIMITS
<br />
<br />COUNTY OF DI::ATH
<br />
<br />Grand Island
<br />aa:A'ESIOENCE. STATE - COUNTY
<br />
<br />NE
<br />
<br />
<br />Va,s KJ No 0
<br />
<br />10. J=l.ACE - (e.g., Whitt:!, alaCk. American Indian.
<br />a,p.IISpeoilyl
<br />
<br />13. NAME OF SPOUSE (If wife. giV8 maiden name)
<br />
<br />16, FATHER - NAME
<br />
<br />Homemaker
<br />FIRST MIDDLE
<br />
<br />Domestic
<br />LAST 17 MOTHER
<br />
<br />James Thompson
<br />
<br />15_ EDUCA nON (SpoClly only highe,' grade pompleleOl
<br />Elementary DrliOl1dary 10-121 College (1-4 or 5"1
<br />
<br />MIDDLE MAIDEN SURNAME
<br />
<br />"a. USUAl OCCUPATION IGw. kind 01 work don. during mast "b,
<br />at working 11f8, BVtHf if fBtirsdJ
<br />
<br />Se1an
<br />
<br />18, WAS DoCOASEO oVER IN U.S. ARMED FORCES?
<br />(Yes. no. or unl(.) (If yes. Qiva war and dales of servicesl
<br />No
<br />
<br />
<br />Mildred
<br />
<br />Dockendorf
<br />
<br />19b. INFORMANT
<br />
<br />MAILING AOORESS
<br />
<br />James Thompson
<br />ISTREI::T OR RF.O. NO" CITY OR TOWN. ST A TE_ ZIP)
<br />
<br />#7 Kuester Lake
<br />
<br />20~/)~;;~:7l73jl1ZM
<br />
<br />22a.'~RAL Ho'Mo--'NA~ I I U
<br />
<br />Grand Island, NE 68801
<br />2la_ METHOD OF DISPOSITION 21 b. DATE
<br />
<br />21p_ CEMETERy OR CREMATORY NAMo
<br />
<br />
<br />o Bu"ol ORemOv., August 23, 200 Westlawn
<br />2ld. CEMI::TERY OR CRoMATORY LOCATION CITY OR TOWN
<br />
<br />STATE
<br />
<br />All Fai ths Funeral Home IiJcromalion ODon.,lOn
<br />22b~ FUNoRAL HOME AOORoSS (STREET OR RF.D. NO" CITY OR TOWN, STATE, ZIP)
<br />
<br />Grand Island, NE
<br />
<br />2929 S. Locust
<br />23, IMMEOIATE CAUSE
<br />PART
<br />I
<br />
<br />st.
<br />
<br />Grand Island, NE 68801
<br />(ENTER ONlY ONI:: CAUSE PER LINE FOR lal, fbi, ANO (ell
<br />
<br />2S0. INJURY AT WORK
<br />Yes 0 No 0
<br />27a_ DATE OF DI::ATH IMo" Day, Yr,)
<br />
<br />M
<br />281. ~~6u~~i~J~~.V itW!!Yt farm, street. factory
<br />
<br />
<br />I Interval bat'w'een onset aM deaUl
<br />I
<br />: immediate
<br />
<br />I Interval between onset and death
<br />I
<br />I
<br />I
<br />I Interval between onset and death
<br />I
<br />I
<br />I
<br />25. WAS CASE REFERRED TO MEDICAl
<br />E"XAMINE;R QR CORONtJ=l?
<br />
<br />ulaL_u_
<br />QUE TO, OR AS A CONSEOUENCE OF.
<br />
<br />Cardiac
<br />
<br />arrest
<br />
<br />Ibl
<br />~UE TO, OR AS A CONSI::QUI::NCE OF:
<br />
<br />Icl
<br />PART OlHE;R SIONIFICANr CONDITIONS - Conditions contributing 10 the death but not related
<br />
<br />II
<br />
<br />26a.
<br />0 Accicl9nt 0 Undet8fmined
<br />0 Suicide 0 Pending
<br />0 HomiCide InvestigatIon
<br />
<br />2Gb, DATE OF INJURY IMo.,Day_ Yf.) 26c_ HOUR OF INJURY
<br />
<br />26g. LOCATION
<br />
<br />STR€ET OR RF_D_ NO.
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />Ei'~
<br />:!Iii
<br />~~ ~
<br />5le
<br />~I
<br />
<br />M
<br />
<br />
<br />2004
<br />
<br />10:30 pm
<br />
<br />2M PRONOUNCED DEAo IHourl
<br />7:16 am
<br />
<br />M
<br />
<br />2Ba.
<br />
<br />2Bb TIME OF DI::A TH
<br />
<br />Au
<br />
<br />ust
<br />
<br />19
<br />
<br />2004
<br />
<br />27b_ DATE SIGNED IMo.. Day., Yr.}
<br />
<br />27c_ TIME OF DEATH
<br />
<br />27d. To the best of my knowledge, dealn oceurred at the time. date and place and due 10 lhe
<br />ca....5e(~l5tated.
<br />
<br />I-"(Signalure and TIlle) ~
<br />2il. DID TOBACCO USE CONTRIBUTE TO THI:: OI::ATH?
<br />
<br />DYES [29 NO 0 UNKNOWN
<br />
<br />28e. On the basis of examinatlo,' ana'Of investig
<br />the time, date and plaCE! and due to a
<br />
<br />~(Si nature a.nd rille
<br />30,a HAS ORGAN OR TISSUE OONATION al::I::N CONSIDERI::D? 30_b W S CO
<br />
<br />DYES Q9 NO
<br />
<br />3-;. -NAME AND ADDRESS OF CoRTlFll::R IPHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY I (Typo or Prml/
<br />
<br />Deputy C Finecy, HCSO,
<br />
<br />
<br />Grand
<br />
<br />NE
<br />
<br />68801
<br />
<br />! . 32a. REGISTRAR
<br />
<br />J2b_ DATE FILED BY REGISTRAR IMO.. Da.._ Yr-!
<br />
<br />SEP 1 0 2004
<br />
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