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<br />~
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTHANfE1itl1MAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIG,lIQfJ;lis1.OlHiooILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITALSJ#f!$f!ci(~_'Wt!ICH IS
<br />THE LEGAL DEPOSITORY FOR V~TAL RECORDS. ~... -",0"['-..:-.=:;~-.~,.:""l...'..'-.'."'~.'.~.'-.'C. ~i "\"~'-.~
<br />
<br />
<br />DA:U: ~S;A?;~ 20070536 9 \~=:Jw~:
<br />
<br />LINCOLN, NEBRASKA ~LTititND'1f!MA-N SEl/VICES
<br />
<br />-.
<br />
<br />-: :'~' -::".. .~..:"." "..:. .. -
<br />
<br />Amended Augus t S;A~~ OZ006ASKA- ~EPAR~~;~rF~Qr;~N~ ~U~~~I_~'_~~SF'NANCE AND SUPPORb n_2'B 461"_
<br />
<br />L D~C~D~NT'S-NAM~ (First, Middle, Lasl, Suffix) 2. SE:X 3, DATE: OF DE:ATH (MO., Day, YrJ
<br />Warren Edwin Lindsey Sr. Male August 1, 20U6
<br />
<br />
<br />4..QITY AND STAn ORJ.I'RRJTORY, OR FOREIGN COUNTRY OF BIRTH
<br />ljangor, !VlaJ.ne
<br />
<br />5a. AG4bl Birthday
<br />(Yrs,j
<br />
<br />5b_ UNDE:R 1 YE:AR
<br />MOS, DAYS
<br />
<br />5c_ UNDE:R 1 DAY
<br />HOURS MINS,
<br />
<br />6. DATE OF BIRTH (Mo_, Day, Yr.)
<br />Sepb 22, 1929
<br />
<br />7,SOCIALSECU~T6~~B~4 _ 4 0 5 2
<br />
<br />aa_ PLACE: OF D~ATH
<br />lillS.I'lIAL: m Inpatlenl
<br />
<br />QlliEB: 0 Nursing Home/LTC 0 Hoaplce Faclllly
<br />
<br />ab. FACILtTY."NAME (If not insiilLJlion, gi'/e 5lrelifl and ntlmber)
<br />st. Francis Medical Center
<br />
<br />o E:R/Outpaliant
<br />
<br />o Decedent's Home
<br />
<br />ao, CITY OR TQWN OF D.('ATH (1'lflud'lJ'ilI t;<.orJf)
<br />Grano IS1ana b~~u3
<br />
<br />o [l)I\ 0 Othar (Spacify)
<br />
<br />r- ---
<br />ad ff~f~rfF DEATH
<br />
<br />--- ------~-----_._...
<br />90. CITY OR TOWN
<br />Grand Island
<br />
<br />9a_ RESIDENCE-STATE 9bH, COaU~T(,
<br />Nebraska 11
<br />
<br />lOa. MARITAL STATUS ATTIME OF DEATH Xl Married 0 Never Ma"led
<br />
<br />---: L~_~:--NO---[-9f61~C~DO 1:_ ______]~_~;s~~~~_iTY~~~:-
<br />
<br />lOb, NAME OF SPOUSE (First, MiddJa, Last, Suffix) Ifwlfa, give maiden name,
<br />LaFern Lindocy P.aR8elllR Van Boening
<br />
<br />9d, STREET AND NUM8ER
<br />502 W.16th st
<br />
<br />o MarrIed, but separated 0 Widowed 0 DIvorced 0 Unknown
<br />
<br />11, FATHER'S-NAME f:l:S~d
<br />
<br />~~Y.old
<br />
<br />L.asl, d Suffix)
<br />Ll.n sey
<br />
<br />12_ MOTHER'S.NAME I:,i1.tla
<br />
<br />Middla,
<br />
<br />RMctW:fo'lp"h
<br />
<br />13, EVER IN U,S, ARMED FORCES? Give dale' of ,ervlce II yes. 14a.INFORMANT-NAME
<br />(Yas, no, orunk,)ieS 2/26/47-2/25/50 aFern Lindsey
<br />
<br />16aI&M~1ME~ffi~~Rf me d
<br />
<br />l4b, RFLATIONSHIP TO DECEDENT
<br />Wl.fe
<br />
<br />o 8urial
<br />
<br />o Donalion
<br />
<br />-I-lab. LICENSE NO_
<br />
<br />.._-~-, ,,'----"--,._,-'.~,.
<br />
<br />16c_ DATE (Mo" Day, Yr.)
<br />8/2/2006
<br />
<br />15, METHOD OF DISPOSITION
<br />
<br />lAcrsmaHon 0 Entombment
<br />
<br />16d. CEMET~RY, CR~MATORY OR OHiER LOCATION
<br />
<br />CITY I TOWN
<br />
<br />STATE
<br />
<br />o Removel UOlher(Speclfy) Central Nebraska Cremation Service
<br />
<br />Gibbon,
<br />
<br />Nebraska
<br />
<br />;':lIfNErllHf~l1A~E "'JtiL~~A~rrESBl3lme~ Cill'1r901iflol~ .
<br />
<br />Locust Grand Island,NE
<br />
<br />17b6i~~t 1
<br />
<br />,\ ",' ,"
<br />
<br />""'
<br />
<br />,',
<br />
<br />PART I. Enler tho chain 01 AVAnl<--dl,ea,ea, In/urlee, or compllcallons--Ihal directly cau,ed the dealh, DO NOT enler lerminal evenla 'uch aa cardiac a"eel,
<br />respiratory arrest, or ventricular fibrillation without showing Ihe etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary,
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onset to death
<br />
<br />IMMEDIATE CAUSE (Final
<br />dt.e.,e or condition resulting
<br />in death)
<br />
<br />(e) ACUTE CARDIORESPIRATORY FAILURE
<br />
<br />I ,
<br />__..__.1 r) lAce O""r:~
<br />I onsel \njealh
<br />I
<br />I
<br />I
<br />I onsel to dealh
<br />I
<br />I
<br />
<br />DUE: TO, OR AS A CONSEQUENCE OF:
<br />
<br />SequenUelly list conditione, II (b) CORONARY ARTERY DISEASE
<br />any, leading to the ceu..II.ted DUE TO, oR- AS A cONs~Qij'ENCE- OF:
<br />on linea,
<br />Enierthe UNOERLYING CAUSE
<br />(disease or Injury that Initiated (c)
<br />theevent,,""ulting In death) DUE TO, OR AS A CONSEQUENCE OF,
<br />lAST
<br />
<br />on,el to dealh
<br />
<br />(d)
<br />
<br />18, PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contribuling 10 the dealh but not re,ultlng in Ihe underlying cau,e given In PART I.
<br />
<br />TYPE 2 DIABETES, CHRONIC OBSTRUCTIVE PULMONARY DISEASE
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES JO NO
<br />
<br />21e. MA~NER OF DEATH 21b.IFTRANSPORTATION INJURY 21c, WAS AN AUTOPS~PERF RMED?
<br />IB'NalUral 0 Homicide 0 Drlver/Operalor
<br />U NOI pregnant within pael year 0 passangar 0 YES 0
<br />o Pregnantal lime of dealh 0 AccldenlD Pending Inve'"ga"on
<br />
<br />U NOI pregnant, bul pregnanl wllhln 42 daya of dealh 0 Suicide 0 Could nol be determined 0 Pedeslrian 21d, WERE AUTOPSY FINDINGS AVAILA8LE TO
<br />o Othar (Spaclly)
<br />o NOI pregnant, bUI pregnanl43 day' 10 1 year bel ore death COMPLETE CAUSE ~DEATH?
<br />
<br />o Unknown If pregnant within the past year 0 YES 2J NO
<br />
<br />-.::~Q~~~Q' I;;J~':I(MO'D.~~~IT::'I[orlll;~H: t- -rt~AI homa, farm, ~t, ta=ry, of;r~e Dundln~__atructr~le, e'c !0pecllYT
<br />
<br />
<br />22d, IN,JURY AT WORK? ne, DESCRIB~ HOW INJURY OCCURRED
<br />
<br />20. IF FfiMALE:
<br />
<br />o YES 0 NO
<br />
<br />22f. LOCATION OF INJURY. STREET & NUMBER, APT NO_
<br />
<br />CITYlfOWN
<br />
<br />',lATE
<br />
<br />ZIP CODE
<br />
<br />23a, DATE OF DEATH (Mo., Day, Yr.)
<br />UGUST 1, 2006
<br />
<br />24a, DATE SIGNED (". ,Oay, Yr,)
<br />
<br />24b, TIM~ OF D~ATH
<br />
<br />z
<br />~~
<br />h
<br />a.:r~
<br />~ll.z
<br />8 g'o
<br />1l'g
<br />~!
<br />-0:
<br />
<br />~~i
<br />]~o
<br />'!l ~ 1= > 24c_ PRONOUNCED DE:AD (Mo., Oay, Yr.) 24d, TIME PRONOUNCED DEAD
<br />a.~~~ m
<br />~." ~ 25
<br />8 ffi z 24e. On (he basis 01 examlna!lon and/or Investigation, in my opinion death occurred at
<br />1l Z =>8 Iha time, dala and place and due to Ihe cause(a) "aled, (SlgnalUre and Tille)"
<br />~~
<br />
<br />_...~..~
<br />25. DID)pBACCO USE CONTRIBUT OTHE DEATH? R TISSUE D,ATlON BEEN CONSIDERED?
<br />
<br />0YE:S 0 NO 0 PROBABLY 0 UNKNOWN 0 YE:S ~NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Prlnll.
<br />Dr. William Lawton 2444 W Faidley AVe. Grand Island, NE 68803
<br />
<br />m
<br />
<br />08:56A11
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />
<br />NOI App!!oable If 26a Is NO 0 YES ~O
<br />
<br />26a, REGISTRAR'S SIGNATURE
<br />
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo" Day, Yr,)
<br />
<br />AUG
<br />
<br />3 2006
<br />
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