|
<br />..
<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 RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSTIG~SEc:flfJl&. WHICH IS
<br />
<br />
<br />:~~;~:i;;;RYFOR::L~:::98~ ~,:
<br />
<br />
<br />LINCOLN, NEBRASKA H~~~:rS
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINAr;JCE)Nb sSJi"PQRfI, g"- 2" 8 71' 0'
<br />_ CERTIFICATE OF DEATH--'-=--_" '...v.a- ' , .' i
<br />1. DECEDENT'S.NAM,(;i't'bert Middle, ctg'rcia
<br />C.
<br />
<br />Sr. Sufllx)
<br />
<br />2.SEX
<br />
<br />\
<br />
<br />i
<br />
<br />I
<br />
<br />-i-
<br />J
<br />
<br />
<br />Male
<br />
<br />. ':FDATE OF DEATH (Mo.. Day, Yr.)
<br />August 5,2_006
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />San Antonio, Texas
<br />
<br />Sa, AGE-Last Birthday 5b, UNDER 1 YEAR
<br />(Yrs,) 66 MOS. DAYS
<br />
<br />5c, UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />6. DATE OF BIRTH (Mo" Day, Yr.)
<br />February 3, 194
<br />
<br />508-44-5080
<br />
<br />6a, PLACE OF DEATH
<br />J:iQ.6flIAI.;
<br />
<br />o Inpatient
<br />
<br />QIl:fER ~ Nursing Home/LTC 0 Hospice Facility
<br />
<br />6b, FACILiTY.NAME (II not institution, give street and number)
<br />Beverly Heakhcare Park Place
<br />
<br />o ER/Outpatienl
<br />
<br />o Decedent's Home
<br />
<br />o~
<br />
<br />o Other (Specify)
<br />
<br />6c, CITY OR TOW.f'l OF DEAIH (Incl'Jlle Zi~ ~~)
<br />Grana ISiana otiti03
<br />EOUNTY Hall
<br />
<br />o Divorced 0 Unknown
<br />
<br />6d'ffc\i1YfF DEATH
<br />
<br />-~~~tftjN Island
<br />
<br />-=lge APT NO rif~1
<br />
<br />lOb, NAME OF SPOUSE (First, Middle, Last, Suftix) It wife, give maiden name,
<br />Pamela Switzer
<br />
<br />~-9g INSIDE CITY LIMITS
<br />Q YES 0 NO
<br />.~- ..,
<br />
<br />St.
<br />
<br />.~- ~-
<br />lOa. MARITAL STATUS ATTIME OF DEATH Xl Married 0 Novor Married
<br />
<br />11. FATHER'S-NAME .if I rsat
<br />Pe ro
<br />
<br />Middle,
<br />
<br />...last, . Suffix)
<br />LiarCl.a
<br />
<br />12, MOTHER'S.NAME
<br />
<br />lOla'ry
<br />
<br />Middlo,
<br />
<br />lA~ltI~r'l ,~urname)
<br />
<br />13, EVER IN U.S, ARMED FORCES? Give dates of service if yes, 14e.INFORMANT-NAME
<br />No Pamela Garcia
<br />
<br />Contreras
<br />14b, RELATIONSlilP TO DECEDENT
<br />Wite
<br />
<br />o Donetion
<br />
<br />
<br />STATE
<br />
<br />16a,
<br />
<br />16c, DATE (Mo., Day, Yr,)
<br />ugust 9,2006
<br />
<br />Q Cremation 0 Entombmont
<br />
<br />Q Removai 0 Other (Specily)
<br />
<br />Grand Island City Cemetery
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, CUy orTown, StatoL
<br />All Faiths Funeral Home 2929 s.
<br />
<br />PART I. Enter the chain of event!i--dlseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrost, or venlflculer fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only Ono causo on a line. Add additionallinas if necessary,
<br />IMMEDIATE CAUSE:
<br />
<br />__Ia) ____ [) e..-I"-i'.,....\,,~....
<br />DUE TO, OR AS A CONSEQUENCE OF;
<br />
<br />onset to death
<br />
<br />IMMEDIATE CAUSE (Final
<br />dleease or condition resulting
<br />In death)
<br />
<br />_Y1:--l"\ th
<br />
<br />onset 10 death
<br />
<br />SaquentlefiyIIstcondltiona,If (b) 5e.~' Z-,.,..(/,l, l.J
<br />any,loadlngtotheceusellsted --DUE'TO, OR AS A CONSEQUiNCioF:
<br />on line e.
<br />EnterthoUNDERLYINGCAUSE ( /1 '"'
<br />(dtse.seo' Injury that Initiated (c) " r' ~
<br />thoa""nta reeultlng In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />I.P6r
<br />
<br />~"--r
<br />onset to eath
<br />
<br />'7 vr ____m
<br />onset to dealh
<br />
<br />(d) GO e_ b
<br />PART II. OTHER SIGNIFICANT CONDITIONS.Conditions contributing to the death but not ,"sulling in the underlying causo given in PART I.
<br />
<br />20. IF FEMALE;
<br />o Not pregnanl wUhin past ye.r
<br />o pregna.nt allirne of death
<br />o Not pregnant, but prognant wllhin 42 days ot death
<br />CI Not pregnant, but pregnam 43 days to 1 year beforo death
<br />o Unknown if pregnarll within the pasl year
<br />
<br />-r:)~
<br />19. WAS MEDI AL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />o YES KNO
<br />
<br />21c, WAS AN AUTOPSY PERFORMED7
<br />
<br />DYES rg;(f,
<br />
<br />[-4- tV
<br />
<br />21 a. ~NER OF DEATH
<br />~Naturai 0 Homicide
<br />
<br />W AccldentO Pending Invostigation
<br />
<br />o Suicide 0 Could not bo determined
<br />
<br />21b, IFTRANSPORTATION INJURY
<br />o DrlverlOperator
<br />
<br />o Passenger
<br />
<br />I:J Pedestrian
<br />
<br />o Other (Spocify)
<br />
<br />DYES 0 NO
<br />
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />22a. DATE_ClF INJURY IMo,,_ a.ey, Yr.)
<br />
<br />nb, TIME OF INJURY 22C. PLACE OF INJURY.At home, farm, street, factory, oflice building, construction sito, otc, (Specify)
<br />
<br />-~~------ --- -
<br />
<br />22d.INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />24a. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />1;~~
<br />~g?gj
<br />~ifS~
<br />g~~~
<br />"wZ
<br />.8~5
<br />$,r:r.O
<br />o~
<br />00
<br />
<br />m
<br />
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr,) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of exa.mination and/or Investigation, in my opinion dealh occurred at
<br />the time, date and placo and duO to the ceuse(s) Slated, (Signaturo and Title) '"
<br />
<br />260, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />DYES 0 NO 0 PROBABLY NKNOWN 0 YES
<br />27:'NAME:TITLE AND ADDRESS OF r"DTI~IER IPHYSICIAN, CORON!'R:.,i'HYSICIAN OR C9ltNTY Ari~
<br />Dr. Chad Vieth 'HD 2116 Fal.aiey SUl. te 4
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />26a, REGISTRAR'S SIGNATURE
<br />
<br />
<br />
<br />""~<:lApplicable it 26a is NO 0 YES____
<br />
<br />Island, Ne 68803
<br />
<br />26b, DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />AUG 1 0 2006
<br />
|