|
<br />..
<br />
<br />....
<br />.
<br />
<br />'"
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH A!'lN!1!!!.~=~ERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGIN1.~-T1EC,,-1!P_P!l'f!lME WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlItTlc;S-SEl?!'OI'Ii-':jl,HlpH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. #. ....=t..Ji...-"=:..~j;--.u: ",oj ~._~i~' "-'~,
<br />
<br />DATE Of ISSUANCE ~:itTff;/sv~C~JR
<br />
<br />~~~. :E;~:KA 2007064:it H~::l;;~~
<br />
<br />
<br />-::; .,':.. '"..- - .- - "",:..
<br />
<br />~.
<br />
<br />
<br />_ STA~_E_~F NEBRAsKA - DE~AR~~~;rF~~;:;~N~ ~U~~~~~~ICES FINANCEA~D_ SUPPo115~_2i1' 2_91
<br />
<br />1. DECEDENT'S-NAME (First,. Middle, Last, Suffix) 2. SEX~ 3, DATE OF OEATH (Mo_, Oay, Yr,)
<br />
<br />-- ----.Ervin_ .Monroe-Hf,or- - ____..MaIe_ --AugusttUOOti
<br />· w",,,,,,, ""'''"''''"' ""'''O,,'"~"' OC ""m " "'C., ""'''1" ~"" m" " """ , ""' . .." OC "''''' ,.... 0". ".]
<br />(Yrs ) MO~AYS HOURS..J-' MINS.
<br />
<br />- Kal.?na, Iowa __ ____ _ __ 6Jl_ --.l__ _ ~embeL25,J936.___
<br />7 SOCIAL SECURII Y NUMBER Ia PLACE OF DEATH
<br />
<br />- ?08-~8-2256 ____ _ _ _ _ HQ.sl'.JIAl. a Inpallent QlliE.8: lJ Nursing Home/LTC OHosplceFacilily
<br />
<br />8b FACILITY. NAME (If nol institution, give slroet and number) 0 ER/Oc!palient 0 Docodon", l-lomo-
<br />
<br />St. Francis Medical Center 0 0Cl'I OOther(Spocify)__ _ __
<br />------ - -----,-
<br />8e, CITY OR TOWN OF DEATH (Include Zip Code) ~Rd'-COUNTY OF Di:A~
<br />
<br />randJsJand.-68801_~_ _ _ __-.-L
<br />9a RESIDENCE. STATE 9b COUNTY - ----rs~,CITYORTOWN -- --
<br />
<br />----"tebraska-_ - ------J,jall__~__ ~_ ~-----Gair_---- _
<br />9d_ STREET AND NUMBER ge APT NO 9f ZIP CODE'-jlig INSIDE CITY LIMITS
<br />
<br />. ...11J13.. W..JI!lbiteCLoudRoad...-u -- r -- - - --- -----.68824... ---.L 0 YES ~_ NO
<br />tOa, MARITAL STATUS AT TIME OF DEATH 'Married [J Never Married 10b NAME OF SPOUSE (Flrsl, Middle, Last, Suffix) If wife, give maiden name
<br />
<br />o Married, but sep.rated 0 Widowed 0 Divorced 0 Unknown
<br />- ------ -- - ___Kamn._Ey~ _ ___
<br />11, ~AT:_R'S-NAME _= --------J::~~st Last,_--=X)__ rHER'S-NAME ~da .su:dle~n-_ Malden surn:_=-
<br />
<br />
<br />13, EVER IN U,S, ARMED FORCES? Give dates of service If yes_ 14e, INFORMANT-NAME 14b, RELATIONSHIP TO DECEDENT
<br />
<br />Hall-- __.
<br />
<br />~
<br />
<br />_(Y.., no, or~nkl\L~.
<br />15, METHOO OF OISPOSITtON
<br />
<br />IliI Burial
<br />
<br />o Donalion
<br />
<br />ts. EMBALMER'SIGNATUR~~.;~ 1't~ILJiI~~~~~=~SE N_~/}'.,?S ..
<br />1Sd CEMETERY, CREMATORY OR ~:~;)N CITY I TOWN
<br />
<br />-,__..w~
<br />160.0ATE (Mo., Oay, Yr, )
<br />
<br />[J Cremation W Enlombmenl
<br />
<br />ugusU-5,2006-
<br />STATE
<br />
<br />o Removel 0 Other (Specify)
<br />
<br />Wood River Mennonite Cemetery
<br />
<br />Wood River
<br />
<br />NE
<br />- -[17b:Zip--
<br />117b- Zip Code
<br />68883
<br />
<br />17a, FUNERAL HOME NAMI: AND MAILING ADDRESS (Street, City or Town, Sfate)
<br />Apfel Funeral Home 411 West 11th St. P.O. Box 126 Wood River Nebraska
<br />
<br />18. PART I. Enter the ~~.nt~--disBasas, InJUries, or compllcations..that directly caused the death. DO NOT enter terminal Bvenls such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing Ihe etiology, DO NOT ABBREVIATE. Enter only one cause on a line. Adrl addlllonalline!1 if necessary.
<br />
<br />,
<br />
<br />I
<br />I
<br />
<br />! onset (0 death
<br />
<br />: .2 ~ek.,
<br />
<br />------______.1.___ ___
<br />f Onset to deaH1
<br />
<br />IMMEDIATE CAUSE,
<br />
<br />IMMEDIATE CAUSE (Final (a) e.'Vz./[;;'t<. ~__
<br />dl....eorcondilionre.ulllng DU ,OR AS A CONSEQUENCE OF:
<br />Indoath) J , !
<br />
<br />seQUen;laliYli.loondillon.,If _u(b){,Il/.. q.(~.y 's t5'-~U-~
<br />.ny,I..dlngtolhacau.elislod OUF TO, O~ A CONSEQUENC : ---...
<br />on line H. O-~
<br />Enlenhe UNDERLYING CAUSE '"
<br />(dl....e or Injury Ih.llnl1lated (e)
<br />the events r.sultlng In dO'lh)
<br />lA'lT
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I
<br />
<br />_~_~(,,'L(;I}<<tLg
<br />
<br />I onset to death
<br />I
<br />I
<br />_1__.__-
<br />! onSet to deatll
<br />
<br />I
<br />~ I
<br />
<br />0':'.1"" ",,,,'; "1"":",;;~omo'" <;;;,.oo. ."";',e" '" ., ,..,"., e",;;~;"" '" ., "",,'.'. ".." ;"" '" ;;;rr;-- ----r'":^;,,:~;:~~:;:;:"'
<br />
<br />C?-?'ttL.e ftcklc/w- __ J_ U YES NO
<br />
<br />o IF FEMALE 21a ~NNER OF DEATH 21b IFTRANSPORTATION INJURY 21c WAS AN AUTOPSY PERFORMI:D?
<br />o NOI pregnant within past year alural 0 HomicIde 0 Driver/Operator ~
<br />o YES NO
<br />o Pregnant alllme of death 0 AccidenlO Pendln91nvesligellon lJ Passenger _._. _____
<br />
<br />o NOI pregnant, bul pregnant within 42 days of dealh 0 Suicide lJ Could nol be delermined 0 Pedestrian 21d_ WERE AUTOPSY FINDINGS AVAILABLE TO
<br />W Not pregnanf, but pregnant 43 days 10 1 year belaro dealh I.J Other (Specliy) COMPLETE CAUSE OF DEATH?
<br />
<br />o Unknownlfpregnanlwlthinthepa,lyear _. __.___ 0 YES 0 NO
<br />- -- - --- - -F;;;;:-- 1--- --- - __on - "-
<br />~~I\IEJ)E INJUBY ~Do~~'~_- _L TI~ OF INJU~: J ffo PLACE OF INJIJMY-A~~,,"," tarn" Slre:t, lacmry, offlUlibuililTng:con."uclfon ,'te, elc, (Sp~
<br />
<br />22d INJURY AT WORK? 12e DESCRIBE HOW INJURY OCCURRED
<br />II YES 0 NO
<br />---- -.--
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT NO, CITYfTOWN SWE ZIP COOE
<br />
<br />23a, DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />24e, OATE SIGNEO (Mo" Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />z,.
<br />~~~
<br />".,'"
<br />n~
<br />CLQ. ~ ~
<br />E"'~Z
<br />o D: 0
<br />"UJ
<br />"Z"
<br />"'00
<br />t2rcU
<br />o ~
<br />uo
<br />
<br />m
<br />
<br />24c_ PRONOUNCED DEAO (Mo_, Day, Yr_) 24d_ TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examlnallon and/or Invesllgelion, in my opinion death occurred at
<br />the lime, dale and place and due to Ihe causers) slated. (Slgnelure and Title) ...
<br />
<br />US CONTRIBUTE TO THE D 26a, HAS ORGAN OR TISSUE OONATION BEEN CONSIDERED?
<br />
<br />NO 0 PROBABLY UNKNOWN 0 YES }/l'N0
<br />D ADORESS OFCER'f1FiER (PHYSICIAN~ORONER;S PHYSiCIAN OR COUN~Yi ('rypoor Print) ----
<br />
<br />John A. Wa a Ave. Grand Island
<br />
<br />26b, WAS CONSENT GRANTED?
<br />~.!iG_~ble If 26a is NO[] YES ~ NO
<br />
<br />280. REGISTRAR'S SIGNATURE
<br />
<br />
<br />NE.
<br />
<br />68803
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />AUG 2 5 2006
<br />
|