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<br />
<br />,
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALl'HANCJ:/J!AM'NSER,VICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE OR(GlfiAI. RECQk'ij,'{)NFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL~AT-ISTld$SEcnijfil,'WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . ~-/ ." ,1 ..' "."
<br />
<br />'--~-/l-..Jj,;.. "
<br />DATE OF ISSUANCE . ~
<br />'7 - ctA';Lliy",..-ri;OPER
<br />ASSISTANT Sf"A1S/FIEciisTRAR
<br />JjEALTHANqHy~~"'s!RVICES
<br />
<br />FEB 2 3 2007
<br />
<br />200706086
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />STATE OF NEBnASKA - DEPAR~~~~F~;~r;~N~ ~U~ENA~~VICE!3riNANC,~~~~~P,Q8f
<br />_,'_'_' _,- " u_ 21 7 6 8._.__
<br />
<br />I. DECEDENT'S.NAME (Firs!, Middle, Lasl, Sullix) 2. SEX 3. DATE OF DEATH (Mo.. Day, Yr.)
<br />
<br />Emf!l_a Caroline FO\;l.!_ffS,i\. Jackie Female February 18, 2007
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE.Lasl Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />(YIS.) MOS. DAYS HOURS M[NS.
<br />
<br />_"~urora, Nebraska
<br />7. SOCIAL SECUR[TY NUMBER
<br />
<br />87
<br />
<br />November 5, 1919
<br />
<br />8a. PLACE OF DEATH
<br />~E.!.M!.
<br />
<br />00 Inpallonl
<br />
<br />OTHER: 0 Nursing Home/LTC 0 Hospice Facility
<br />
<br />"
<br />
<br />505-12-3616
<br />8b. FAC[L1TY-NAME (If nol Inslilufion, give slr..t and number)
<br />
<br />o ER/Outpatlenl 0 Dece~enl's Home
<br />
<br />a;
<br />12
<br />u
<br />UJ
<br />a;
<br />is
<br />..J
<br /><(
<br />a;
<br />I1l
<br />:z
<br />::>
<br />LL
<br />
<br />Saint Francis Medical Center
<br />8e. CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />u CO\ 0 Olh., (spectlyL
<br />8d. COUNTY OF DEATH
<br />
<br />Hall
<br />
<br />Grand Island 68803
<br />9a. RES[DeNCE.S IAlE
<br />
<br />9b. COUNTY
<br />
<br />90. CITY OR TOWN
<br />
<br />i Nebrask8 Hall Grand Island
<br />
<br />~ -~~:R~:~~~D;~::ER-- .---- ---~---.---.Ige. APT. N~1DE
<br />
<br />~ 10a. MARITAL STATUS AT TIME OF OEATH 0 Married 0 Never Marned lOb, NAME OF SPOUSE (First. Middlel Last, Suffix) II wilel give maiden name.
<br />2
<br />..
<br />~ 0 M..lleU, bul separale~ llIl WidOWed 0 Dlvorce~ 0 Unknown
<br />o
<br />U
<br />.. 11. FATHER'S.NAME (First, M[ddle, Lasl, Sullix) (Fltst, Middle.
<br />w
<br />~ Alfred Peterson
<br />
<br />9g. [NSIDE CITY LIMITS
<br />lil YES U NO
<br />
<br />
<br />Malden Surname)
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />niece
<br />
<br />16c. DA1E (Mo.. Day, Yr.)
<br />
<br />February 22,2007
<br />
<br />STATE
<br />
<br />13. !':VEn [N U.S. ARMED FORCES? Give dales 01 .ervlcollyes. 14a.INFORMANT.NAME
<br />
<br />lYe', no. orunk.) No
<br />
<br />15. METHOD OF D[SPOSITlON
<br />
<br />llIl BUlial U Donalloll
<br />
<br />Mary Nefzger
<br />BALMER.SIGN~RE
<br />. K. 'Q.u-~.::e:c-
<br />
<br />_==r_L1C~N;~;O.
<br />
<br />CITY I TOWN
<br />
<br />
<br />160
<br />
<br />U CremailOn U Enlombmenl
<br />
<br />16d. CEMETERY. CREMATORY OR OTHER LOCATION
<br />
<br />o Removal 0 Olher (SpeClly)
<br />
<br />Nebraska
<br />17b. Zip Code
<br />68803
<br />
<br />Aurora Cemetery
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS ISl,eel, City or Town, St. Ie)
<br />Livingslon-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />
<br />Auror.a
<br />
<br />CA.IJSE OF DEATH (Sn~n$truc!ion~and.,exampJ8s)...-~"
<br />19. PART I. Enlerlhe gmiJl.Ql~udiseases, injurl... 0' complicalionsulhal dlreolly cause~ Ihe dealh. DO NOT enler termin.1 events such as cardiac ar,esl,
<br />respif~lory <lHest. orventl'jcul~r fi\)rillallon without showing the ellology. DO NOT ARBRf.VIATE. Enter only one caUSe on a line. Add ~ddlllonallines if necessary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMf.P[ATE CAUSE,
<br />
<br />J"set to dealh
<br />
<br />> S 'I V'~
<br />
<br />IMMEDIATJ;CAUSE(Fklal ~O_e 0 ex~~U.. (" b o.....:;hoYl
<br />
<br />dls....o'eol1dlllo'....u[Url\i DUE TO, OR AS A CONSEQUENCE OF:
<br />in dealh)
<br />
<br />Sequentially 11.1 condlllon.,If (b) A, F ;.b
<br />any, I.adlng to llle eau.ellslad DUE TO, OR AS A CONSEQUENCE OF:
<br />on line a.
<br />Enter UlO UNDERLYING CAUSE
<br />(dlsea.e 0' InJUry Ihalln llIat.d Ic)
<br />Iho events re.ulllng In deaUl) DUE TO. OR AS A CONSEQUENCE OF:
<br />lAST
<br />
<br />or1C~~:~ dr.:::dlll
<br />
<br />> yr-
<br />
<br />onset to dealll
<br />
<br />on.ello ~..lh
<br />
<br />(d)
<br />
<br />18. PART [I. OTHE R SIGNIFICANT CONDIIIONS-Conditions conlribullng 10 Ihe ~ealh bul not re5ulllng in the underlying cause given In PART I.
<br />
<br />I,tWAS MEDICAL EXAM[NEH
<br />
<br />OR CORONER CONTACTED?
<br />
<br />DYES
<br />
<br />Il!l NO
<br />
<br />a;
<br />I1l
<br />u:
<br />~
<br />UJ
<br />u
<br />i
<br />-0
<br />."J
<br />..
<br />-a.
<br />E
<br />8
<br />..
<br />rn
<br />{1.
<br />
<br />YtMANNER OF DEATH
<br />. Nalural 0 HomiCide
<br />
<br />. .
<br />~L [F TRANSPORTAT[ON INJURY 'fC. WAS AN AUTOPSY PERFORMED?
<br />U Driver/Operalo'
<br />DYES
<br />
<br />JICIF FEMA[.E:
<br />
<br />
<br />i1 Nol pregnant wilhln pasl year
<br />
<br />U P'egnanl al time ot dealh
<br />
<br />o Nol pregnanl, but pregnant within 42 days 01 death
<br />
<br />U Nol pregnanl, bul prognanl43 days 101 yearb.lo,o death
<br />
<br />8 lInKnowmtj1r.gn.nl witnrn lhe p..t year--- ~-.---.
<br />
<br />o Passenger
<br />
<br />Mho
<br />
<br />o AccldenlU Pending Investigation
<br />o Suicide U Could not be dele,mlned
<br />
<br />o Pede.trian
<br />U Olhe, (SpeCify)
<br />
<br />2)4 WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />~ --- ill1v
<br />
<br />22a. DATE OF INJURY (Mo.. Day, Y,.)
<br />
<br />22b. TIME OF INJURY
<br />
<br />220. PLACE OF INJURY-AI homa, la,m, slreet, lactory. olliee building, consltucllon .ite. elC. (Spoclfy)
<br />
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />22e. DESCR[BE HOW INJURY OCCURRED
<br />
<br />U YES 0 NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUM8ER, ArT. NO.
<br />
<br />CITY /TOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />z
<br />>...;
<br />"'-
<br />TIs,>
<br />.;~
<br />o..::.c::J
<br />EILZ
<br />8 g>o
<br />Q)1J
<br />'" c
<br />o ..
<br />>-=
<br /><(
<br />
<br />)40. DAlE OF DEATH (Mo.. D;;:-Yr.)
<br />'2.. - J 6 -- 7-- () 07i-
<br />.~. DATE S[GNED (Mo'.-~ay. Yr.) "
<br />2'---IQ-.O-7-- m
<br />2 . To the best of my knowledge. death occurred allhe time, dale and place
<br />.nd due 10 1I1e ~ause(s) sl.ted. ISignalure .naJllle)...
<br />:Y?-e_~r)
<br />
<br />24e, On the basis of examinallon and/or investigation, In my opinion death occurred at
<br />Ihellme, date and place and due 10 the causels) slaled. (Slgn.lule and T[lIe)...
<br />
<br />24a. DATE SIGNED IMo.. Day, Yr.)
<br />
<br />24b. T[ME OF DEATH
<br />
<br />z>-
<br />"';w
<br />>-~ Z
<br />.a~tt
<br />"2~o
<br />~5:~::'
<br />EW>-Z
<br />00:1-0
<br />"wZ
<br />..z:l
<br />"'00
<br />~C(u
<br />a_
<br />u 0
<br />
<br />m
<br />
<br />
<br />24e.1'110NOUNCED DEAD (Mo.. Day, Y,.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />
<br />'f DID TOBACCO USE CONTRIBUTETOTHE DEATH? . HAS ORGAN OR TISSUE DONATION BEEN CONSIDEnED" frtl. WAS CONSENT GRANTED?
<br />
<br />III YES U NO U PROBABLY U UNKNOWN U YES IS NO Not Applieablel126a if. NO 0 YES U NO
<br />1 N~ME, TITI F A~D A.DDRESS OF CERTlrtER IPHYSICIAN, CORONER'S PHYSIC[AN OR COUNTY ATTORNEY) (Type orprlnll.' '. ..-
<br />\ (2.-. 0 '((')r0(\ "- I .L "I W C LJ6-te.r 'y" o-I"IdI S l~l...nd 10--e; to 280~::!
<br />
<br />28b. DA1E FILED BY REGISTRAR (Mo" Day, Yr.)
<br />FEB 2. li LUOl
<br />
<br />
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