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<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-RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL.$~Tt$~_~/ON, WHICH 15
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS'/ff~l~tJ;;~_~,e....,
<br />
<br />
<br />DATEAopFRISS1U;t~~07 2 0 0 70 3 812 j/ -;'ri~: ~;?J~N~~ lCOOPER
<br />'c'" AsfSlSTANT sTAtEc"RIt:GISTRAR
<br />"- ~~J: -- -:'::f(~ALTHAND~iiE'RVfCES
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />r STATE OF NEBRASKA - DEPAR~~R-nF7~f;E~~lJOE1t;,.~~~~~r:~;tb;Jt{T 24220
<br /> 1\ ~~.~' .
<br /> I. DECEDENT'S.NAME (First, Mlddlo, Last, Sufllx) .~=:-:- 2;.8 EIt.o_.-'.__-',O::= 3. DATE OF DEATH (Mo" Day, Yr.)
<br /> ! John Ross Lincoln Male April 11, 2007
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE-Laol Birthday Sb. UNDER 1 YEAR Sc, UNDER 1 DAY 6. DATE OF BIRTH (Mo" Day, Yr.)
<br /> '. tY".) MOS. I DAYS HOURS I MINS.
<br /> Beatrice, Nebraska 71 February 2, 1936
<br /> 7. SOCIAL SECURITY NUMBER Sa, PLACE OF DEATH
<br />"'" 507-40-2308 J:J.Q.af.lJA.L: iii Inpallent Qllllill: o Nursing HOmll/LTC o Hooplce Faclllly
<br /> 't 8b. FACILlTY.NAME (II not Institution, glva stre.t and number) o ER/Oulpetlent o Decedent's Home
<br /> t
<br /> ~ Saint Francis Medical Center OIXA o Ot11eqSpeClly)_ ,...------
<br /> is
<br /> ~ Be. CITY OR TOWN OF DEATH (InclUde Zip Code) I Bd. COUNTY OF DEATH
<br /> Grand Island 68803 Hall
<br /> z Ba. RESIDENCE.STATE I Bb. COUNTY I Be. CITY OR TOWN
<br /> ~
<br /> j Nebraska Hall Grand Island
<br /> '\:J Bd. STREET AND NUMBER .t. APT. N~l~' ZIP CODE I Bg.INSIDE CITY LIMITS
<br /> ..
<br /> ;;:;
<br /> ~ 1711 Idlewood Lane .. .. ~ 68803.. GiI YES 0 NO
<br /> lOa. MARITAL STATUS ArTlME OF DEATH Iil Married 0 Never Married lOb. NAME OF SPOUSE (First, Middle, Lasl, Sufllx) II wire, give maiden name,
<br /> li
<br /> Ci. o Marned, bulseparated 0 Widowed o Divorced 0 Unknown
<br /> ~ Patricia Clayton
<br /> .. \1. FATHER'S.NAME (Flrot, Middle, Last, Sulllx) 1'2' MOTHER'S-NAME (First, Middle, Malden Surname,
<br /> III
<br /> {!. Ross Lincoln Irene Hill
<br /> 13. EVER IN U.S. ARMED FORCES? Give dales or salVlcellyes'114a. INFORMANT.NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yes, no, or unk.) Patricia Lincoln Wife
<br /> 15. METHOD OF DISPOSITION 16~~:~~1'/)~h ,;; 116b/~7 ( 16c. DATE (Mo" Day, Yr. )
<br /> IlII Burial o Donallon April 14, 2007
<br /> o cremallon o Entombment 16<rcrMETERY, CREMATORY OR OTHER LOCATlo41 CITY /TOWN S TATE
<br /> o Removal o Other (Specrly)
<br /> Grand Island City Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreet, Clly orTown, s'aleN /'7b. Zip Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, ebraska 68801
<br /> CAUSE OF DEATH-(!rll Instructions and examples)
<br /> 18. PART I. Enler Ihe ~lIll..dlse..es, InJu~es, 0' compllcallons..lhat dlreclly caused Ihe death. DO NOT enler terminal evenls such.s cardiac arre,l, APPROXIMATE INTERVAL
<br /> I
<br /> respiratory arresl, or ventricular flbnllatlon wllhoul showing the ellolO\lY. DO NOT ABBREVIATE. Enter only one cause on a line. Add addlllonalllnesll necessary. I
<br /> IMMEDIATE CAUSE: I onset 10 death
<br /> I
<br /> (a) J\ C LJTC'~ MI: I 3LP hOlJvS
<br /> IMMF.D!ATE CAU(lE(Fl;el I
<br /> dlseaa. orcondlllonreaultlng DUE TO, OR ASA CONSEQUENCE OF: I on,.tlo death
<br /> ., death) I
<br /> (b) PQI( lC...inson '5 I '> c YF3
<br /> . Sequentially lIatc.ndlllons, It I .J
<br /> any, I.adlng 10 the cauae IIsled DUE TO, OR AS A CONSEQUENCE OF: I onsello death
<br /> .n IIn... I
<br /> Enter 11. UNDERLYING CAUSE \ n \-e v-u I-e. \0Yt^-t N. VY\OY ( h (A.O\E':., I '/& I'Y\ o()+0't:;
<br /> (dla.aa. or Inlury thai initiated (c)
<br /> the even to ..aullng" deat11) DUE TO, ORAS A CONSEQUENCE OF: I on.et 10 daath
<br /> lAST
<br /> I
<br /> (d) I
<br /> 18, PART II. OTHER SIGNIFICANT CONDITIONS.Condltlon. oont~butlng to the death but nolresultlng In Iha underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTEO?
<br /> DYES )( NO
<br /> a: 20. IF FEMALE: 21a. MANNER OF DEATH 21b.IF TRANSPORTATION INJURY 210, WAS AN AUTOPSY PERFORMED?
<br /> W
<br /> u:: o Nol pregnanl within pa't year l:i.Nalural 0 Homicide o Dnver/Operator
<br /> iij DYES ~NO
<br /> ~ o Pregnanl at lime 01 daath .0 AccldenlO Pending Invesllgatlon o pa.sengar
<br /> j o Not pregnant, but pregnanl within 42 day. .1 deat11 o Pedestnan 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br /> o Sulclda 0 COUld nol ba dalermlnad
<br /> i o Nol pregnant, bUlpregnanl43 days to 1 yearbelore deet11 o Ot11er(Speclfy) COMPLETE CAUSE OF DEATH?
<br /> Ci. o Unknown If pregnent within Ihe past year DYES ONO
<br /> e
<br />g 22a. DAfE OF INJURY (Mo.,lJay, Yr'r - f22D.Tf1i1rOF' INJUR: ic,1>tAUt U~ INJUHf,mOr1le, 'arm, Streer,'lIewry;-omcnnnldlng, con&tructtlJllstte, el.-, ~.clry) _...
<br /> .!.
<br /> {!. 22d.INJURY ATWORK? 22e. DESCRIBE HOW INJURY OCCURREO
<br /> DYES 0 NO
<br /> 221. LOCATION OF INJURY. STREET &. NUMBER, APT. NO. CITYITOWN SlATE ZIP CODE
<br />\.
<br /> \ 23a. DATE OF DEATH (Mo., Day, Yr.) z>- 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> ~~ April 11 . 2007 !'~~ m
<br /> "" is.! )lillt
<br /> ilg! 23b. DATE SIGNEQ (Mo., Day, Yr.) I 230, TIME OF DEATH ~@ 24c, PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />'. ~ ~5:~ \.."/1 ;3/ o7j- 6 : 2 4 p. m 0.... <l ~ m
<br /> 8-"' /: Z
<br />~...... B g>o 23d. To Ihe best 01 my knowledge, dealh occurred althe lima, dale and place uffizO 24e. On t11e basis otexamtnatlon and/or Invesllgallon, In my opinion dealh oocurrad al
<br /> --:.::. .x'il and due 10 IhW~::nure and TIlla),. ._ ..z:;;> Ins lima, date and place and duelo the cause(s) .Ialed. (Slgnalura and Tilla),.
<br /> "'00
<br /> ~~ ~a:O
<br /> (,-_." ~V) 815
<br /> 25, DID TOBACCO USE CONTRIBUTE TO THE DEATH? 12Ba. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? I 26b. WAS CONSENT GRANTED?
<br /> DYES ''llQ NO o PROBABLY o UNKNOWN DYES t)t'NO Nol Applicable If 26a I. NO 0 YES o NO
<br /> 27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) ('!Ype orpnnt) Nebraska 68803
<br /> Jennifer Brown M.D., 729 N. .Custer Ave..., Grand Island, .
<br /> 28a. REGISTRAR'S SIGNATURE jJl&~J. (;,~ 2Sb. DATE FILED BY REGISTRAR (Mo., Day, Yr,)
<br /> p APR 1 4>> 2007
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