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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 RECORO-QN-FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSTlf?Fl~!IO'1i~1;! IS
<br />
<br />
<br />:;~;:~~:~i5~RY FOR VITAL RECOROS #PjK~~1
<br />
<br />2 0 0 7 0 5 1 4 5 ASStSTAN.TSTATE REOjSTRAfI:
<br />LINCOLN, NEBRASKA HEAL~~'ANl( 'f,!I}fAN S~I}~tCEii
<br />- ~~,~,~_~~'~~'~-'~'= ~::2~:.,_~~_. _, ~
<br />
<br />. ..--
<br />
<br />
<br />~
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORTO 5 0 59 8 5
<br />._______ CERTIFICATE OF DEATH ..-'
<br />
<br />DECEDENT'S-NAME (Firsl,
<br />
<br />Middl@,
<br />
<br />Last,
<br />
<br />Sulflx)
<br />
<br />2. SEX
<br />___.___Mal~
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a. AGE.Lasl Birthday 5b. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />.. _..t1!l_L2.L 2005
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />AlexandJ~~:r:_ Micl:l1!..~1 Nahorn
<br />
<br />BrooktYDL__N ew_Iprk
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />82
<br />
<br />March 30
<br />
<br />1 92 ~__
<br />
<br />8a. PLACE OF DEATH
<br />
<br />099-12-3323
<br />
<br />I::IQSEJIAL
<br />
<br />rl-Inpalient
<br />
<br />OTl::!E;R: 0 Nursing Home/LTC U Hospice Faclllly
<br />
<br />8b. FACILITY-NAME (It not Institution, glva street and numbar)
<br />
<br />o ER/Outpatient
<br />
<br />o Decedent's Home
<br />
<br />St. Francis Medical Center
<br />
<br />Oro\
<br />
<br />o Other (Specify)
<br />
<br />8c. CITY OR TOWN OF DEATH (Includ. Zip Code)
<br />Grand Island 68803
<br />
<br />ed. COUNTY OF DEATH
<br />Hall
<br />
<br />ge. RESIDENCE-STATE
<br />
<br />9b. COUNTY
<br />
<br />9c. CITY OR TOWN
<br />
<br />""J
<br />
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />
<br />Hall
<br />
<br />
<br />91. ZIP CODE
<br />
<br />2130 E, Wildwood Dr.
<br />----;O~.MARITAL S;:;\TUSATTrME-OF DEATH-'~ Married U N.v.r Merrled
<br />
<br />68801
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />0{ YES 0 NO
<br />
<br />lOb. NAME OF SPOUSE (First, Middle, La.l, Sulflx) If wife, glv. m.ld.n nam..
<br />
<br />o Marriedl bul separated 0 Widowed 0 Divorced 0 Unknown
<br />
<br />11. FATHER'S.NAME (Firsl,
<br />John
<br />
<br />Middle,
<br />
<br />LaSI,
<br />Nahorn
<br />
<br />
<br />Carolyn Krolikow~ki
<br />12. MOTHER'S.NAME (First, Middle,
<br />Constance
<br />
<br />Mald.n Sum.me)
<br />Mueller
<br />
<br />13. EVER IN U.S. ARMED FORCES? Glv. dat.. of ..rvlc.1f y...
<br />y.X,li;'~lInk)11::; _
<br />15. METHOD OF DISPOSITION
<br />
<br />14.. INFORMANT-NAME
<br />
<br />JCJ Cramatlon 0 Entombmant
<br />o Removal 0 Olher (Spacify)
<br />
<br />CITY I TOWN
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />160. DATE (Mo., Day, Yr. )
<br />m _ M a,J'__..2~2__,--) QO 5
<br />STATE
<br />
<br />o Burial
<br />
<br />o Donallon
<br />
<br />
<br />1071
<br />
<br />Central Nebraska Cremation Service
<br />
<br />dibbon, Nebraska
<br />
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Slreat, Cily or Town, Stafe)
<br />
<br />2929 S.
<br />
<br />r..plr.lory .rre'l, or ventrlculer fibrillation without 'howing tha eliology. DO NOT ABBREVIATE. Enler only one c.u.. on . line. Add .ddltionalllneslf nec....ry.
<br />
<br />IMMEDIATE CAUSE (Flnel
<br />disease or condition resulting
<br />In daath)
<br />
<br />
<br />onset to death
<br />
<br />Sequentially IIsl conditions, If
<br />.ny, teedtng to the c.u.ellsted
<br />on IIns a.
<br />EnlOr 'he UNOERLYING CAUSE
<br />(dl..... or Injury th.tlnltlat.d
<br />the event. re.ultlng In death)
<br />lAST
<br />
<br />rJ.-U-d 1-r2,A_C t:<,,-~
<br />
<br />7/1J 'F
<br />?f ~"U-d)
<br />
<br />onset to death
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(c)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Onset to death
<br />
<br />(d)
<br />
<br />Ie. PART II. OTHER SIGNIFICANT CONDITIONS-Condilions confributing to Iha d.afh but not re.ulting In the und.rlylng caus. given In PART I.
<br />
<br />
<br />. .i;_,-t-!:rt}~~l~ C1x.."12 (Jio 1lA.. ". . ,,';iJJ..j L_m~Lfl;+/~-(lIl<<A-~
<br />
<br />20 If FEMALE: 21a. MA;J;ER OF DEA~V[l.'lf 21b.IFTRANSPORTATION INJURY
<br />o Nol pregn.nt within p." year \1 N.tur.t 0 Homicide 0 Drlver/Operelor
<br />
<br />o Pregnantet time of d.ath 0 Accident 0 Panding Invesligation 0 P.ss.ngar
<br />
<br />o Not pregnanl, but pregnanl within 42 days of d.ath 0 Suicld. U Could nol b. d.l.rmlned 0 Pedestrian
<br />o Nol pragnant, bul pregnant 43 days 10 1 y.ar b.for. dealh 0 Olher (Sp.clfy)
<br />o Unknown if pregr.anl within the past year
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />DYES 0
<br />21c. WAS AN AUTOPSY PE FORMED?
<br />
<br />._~Sn_1!-_
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />22.. DATE OF INJURY (Mo., D.y, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, .tr.el, f.otory, 01110. building, construotlon .lle, etc. (Specify)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />DYES 0 NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />240. DATE SIGNEO (Mo. Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />23c. TIME OF DEATH"
<br />10:09 Am
<br />
<br />>=>-
<br />:s-~~
<br />_II:
<br />llg!Q
<br />tf5~
<br />E oW t >=
<br />8ffizO
<br />1:>==>
<br />00
<br />~a:O
<br />o.
<br />0"
<br />
<br />m
<br />
<br />240. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examination and/or Investigation, In my opinion death occurred al
<br />thelim., date and place and due 10 the cause(.) Slated. (Signature and Title) "
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION 6EEN C~NSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />NO 0 PROBABLY 0 UNKNOWN 0 VES Not Applicable If 26a is NO 0 YES 0
<br />A ADDRESSOF'-CERTiFIER '(pHYSICIAN, CORONER;S PHYSICIAN OR COUN ATTORNEY) (Type or Print)
<br />r. John A Wagoner MD 800 Alp.a Grand Island.Ne 68803
<br />
<br />
<br />26b. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />
<br />26a. REGISTRAR'S SIGNATURE
<br />
<br />MAY 2 6 2005
<br />
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