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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.RJieDRP ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL sT~t!~i~ WHICH IS
<br />
<br />:::;::~::::::~TORY FOR VITAL RECORDS. !~-~~~~:~'I~~
<br />,e'!H~';Y$'PiioPER
<br />~. l1SSISfANT$~ REGISTRAR
<br />t#ji!Jif,.!!~~QH~M~ti,S~RVICEs
<br />
<br />AUG 1 6 2005
<br />
<br />200704699
<br />
<br />LlNCOLN,NEBRAsKA
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANC~ AND SUPPORT 0'" . 5 0 7 9 8 7
<br />CERTIFICATE OF DEATH '
<br />
<br />'''-
<br />
<br />
<br />Male____.;[~ly 12, 2005
<br />
<br />1,DECEDENT'S-NAME (First,
<br />Lawrence
<br />
<br />Middle,
<br />Jose h
<br />
<br />Lasl,
<br />Locascio
<br />
<br />Suffix)
<br />
<br />2, SEX
<br />
<br />3. DATE OF DEATH (Mo" Day, Yr,)
<br />
<br />Illinois
<br />
<br />5e. AGE.Lesl Birlhday 5b, UNDER 1 YEAR
<br />(YiS,) MOS, DAYS
<br />84
<br />
<br />50, UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />6, DATE OF BIRTH (Mo" Day, Yr.)
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />August 29, 1920
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />347-22-8377
<br />-- ,...---.--.-...-....
<br />
<br />8a, PLACE OF DEATH
<br />
<br />HoSpITe.L:
<br />
<br />o Inpallenl
<br />
<br />QlliEH 121 NursIng Home/LTC 0 Hospice Facility
<br />
<br />Ah. FACILITY.NAME (If nol instllutlon, glv. str..1 and numh.,)
<br />
<br />o ER/Oulp"II.nl
<br />
<br />o D.c.d.nl'. Hom.
<br />
<br />Beverly Healthcare
<br />
<br />00)\
<br />
<br />o Olher (Sp.ollyL___m.
<br />
<br />8c, CITY OR TOWN OF DEATH (Includ. Zip Cod.)
<br />
<br />9b, COUN ry
<br />Cook
<br />
<br />
<br />8d, COUNTY OF DEATH
<br />Nance
<br />
<br />68638
<br />
<br />9d, STREET AND NUMBER
<br />
<br />----r9 -INsIDE-ciTY LIMITS
<br />68463 IS YES 0 NO
<br />-- --- --
<br />
<br />,"-~tQl__ A!:Ql1;!"llCl. IJIL______.______
<br />10a, MARITAL STATUS AT TIME OF DEATH 0 Marrl.d 0 Never Marrl.d
<br />
<br />lOb, NAME OF SPOUSE (First, Mlddl., last, Suffix) ff wil., glv. maid.n nam.,
<br />
<br />o Married, but separated !JtWldowed 0 Divorced 0 Unknown
<br />
<br />t t, FATHER'S-NAME (Flr.I,
<br />
<br />Mlddl.,
<br />
<br />Last,
<br />
<br />Sutll.)
<br />
<br />12. MOTHER'S.NAME (First,
<br />_AngelJna
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />
<br />Modica
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />
<br />Son
<br />
<br />o Cremation
<br />
<br />Locascio Jr.
<br />161j,l,ICENSE NO,
<br />_8i.
<br />
<br />CITY !TOWN
<br />
<br />160, DATE (Mo" Day, YL)
<br />July 16, 2005
<br />
<br />STATE
<br />
<br />DR.moval OOl~.r(Sp.c) Res rrection Catholic Cemetery Justice
<br />./
<br />--l7a-FUN~AL HOMENAM-EiiNDMAllI;i~~~RESS (Slr..I,Ciiy or Town, Slat~ alme~'9~uOe0a']f!J~a' l to. Box JJ2.
<br />
<br />Zimmerman & Sandeman Funeral Home Orland Park
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />PART I. Ent.r Ihe chaln.oJe~~Ola--dlsease', InJurl.s, or complloatio",--I~al dlr.clly caus.d the d.al~, DO NOT .nl.r I.rminal.v.nl. such as cardiac arrest,
<br />respiratory arrest, Or ventricular fibrillalion wllhoulshowlng the ellology. DO NOT ABBREVIATE. Entaronly ona cause on a line. Add addi1ionallinas if necessary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />IMMEDIATE CAUSE (Final g~11,A~ Arr4.JJ-
<br />disease or condition r..ultlng (al ,
<br />DUE TO, OR AS CONSEQ E CE OF'
<br />Ind.ath) 0
<br />
<br />Sequentl.lly lI.t condition., If (hill c.,(~ )1- '(;11 (UI"L J~ n'v-t;L
<br />any, I.adlng 10 Ih. CHU.. ti.l.d ---'Duii TO, OR AS A~ONSEQUENCE OF:
<br />onllnea. ~
<br />Enl.rlh.UNDERlYINGCAUSE ,
<br />(dl..... or Injury th.t Inltl.t.d (c) fl) z- '" In'/ e ( ~ h1elf (-1
<br />Ih. .v.nl. r..ultlng In d..th) . "'ilu E TO:' 6'Fi-ASACONS'EQUENCE OF:
<br />L.6Sf
<br />
<br />ons.lto d..I~
<br />
<br />ons.t 10 d..l~
<br />
<br />onset to death
<br />
<br />onsello death
<br />
<br />(d)
<br />
<br />21a. MANll'"WF DEATH
<br />lY1iIalural [J Homlcld.
<br />
<br />21b,IFTRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />"119 WIi'S'MEDiCAL.--EXAMINER
<br />OR CORONER CONTACTED?
<br />U YES ~
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS,Condilions conlrlhutlng 10 Ih. d.alh bul not ,..ulling In Ih. und.rlylng cau.. glv.n In PART I.
<br />
<br />o Acoid.nlO P.ndlng Inv..tlg.llon 0 P....ng.r
<br />U Nol pr.gnonl, bul pr.gn.nl wll~ln 42 day. 01 d.alh 0 Sulcid. 0 Could not b. determined 0 Pede'lll.n 21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Not pregnant, bUI pr.gnant 43 days to 1 year b.lor. d..lh U Olh.r (Sp.cily) COMPLETE CAUSE OF DEATH?
<br />o Unknown if pregnant within Ihe pa'l year U YES 0 NO
<br />U., D~~ W1N~VAY (MO., Dew. Yr,) .l~~~:-~~:T~~E~~:A~; ~.m,wut, f.eIO;Y'Of"Mb.~~~,e""-.tr~~lIo:~II.'.lc::~sPaoffY) .
<br />
<br />
<br />22d, INJURY AT WORK? 22.. DESCRIBE HOW INJURY OCCURRED
<br />
<br />DYES
<br />
<br />~
<br />
<br />I.J YES 0 NO
<br />
<br />221. lOCATION OF INJURY" STREET & NUMBER, APl NO.
<br />
<br />CI'TYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />24a, DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />Nb, TIME OF DEATH
<br />
<br />m
<br />
<br />>-;: ~
<br />.cuz
<br />1lCii[5
<br />;;~l:
<br />la..<c~
<br />~1:z
<br />uf5z0
<br />,8z=>
<br />00
<br />{lrr:.u
<br />o ~
<br />U 0
<br />
<br />m
<br />
<br />No, PRONOUNCED DEAD (Mo" Day, Yr.) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />248. On the basis of examlnalion and/or lnvesligalion, in my opinion death occurred at
<br />thallme, d.l. .nd plae. and du.lo Ih. cau..(s) sl.l.d, (Signature and Titl.),.
<br />
<br />25, DID TOBACCO. U USS";9E C r./ff'liil ETOTHE DEATH? 26a, HAS ORGAN OR TISSUE DON/-,. liON. .6. EEN CO....N. S...I.D. ERED?
<br />
<br />DYES h 0 PROBABLY U UNKNOWN U YES ~__,.
<br />27:NAME, TITii AND ADlJRESS OF CERTIFIER (PHYSICIAN, CORONER'S P~IYSICIAN OR COUNTY ATTORNEY) ii'yp. o;p;i~t)'
<br />~oel Travis M.D., 1019 S. 8th st, Albion, NE 68620
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />Net Appllcabl. 1128a isN.O, 0 YES 0 NO
<br />
<br />28., REGISTRAR'S SIGNATURE
<br />
<br />
<br />28h. DATE FILED BY REGISTRAR (Mo.. Day, Yr,)
<br />
<br />JUL 2 0 2005
<br />
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