|
<br />~"'::.'.;'''''7'""'~~'",''IIF'''''.''''''~
<br />
<br />'J
<br />
<br />STATE OF NEBRASKA
<br />
<br />~
<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 RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />
<br />
<br />:::~~:~:Csr;RY FOR V~AL RECOROS ~lJ:r:;~.
<br />
<br />SEP 1 4 2007 AsSlSTAf.Ir;S,!Mi.REG/S."EMR;r,
<br />LINCOLN, NEBRASKA 2 0 0 7 0 8 5 2 8 HEAL~It~N~~~:I!N sER'lI~'/'
<br />
<br />i_ ~ .:'-4", ,..1: ~r ,1
<br />; ";.~~ .. .,L. '''', ,_ '... _,~ .II. ~:,' ,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERv'ICE~fl~NCE AND SUpp ~ <'~2""9 7 4'4'
<br />_~....__"_ CERTIFICATE OF DEATH i "c"".'.' '.' . . ,'1. .
<br />2. ~I:X . ;';;; t..' . 3~ DATE'OFDEAUt'(MO.. Day. Yr.)
<br />Male September 4. 2007
<br />
<br />
<br />1. DECEDENT'S-NAME
<br />
<br />(First,
<br />Jack
<br />
<br />Middle,
<br />Gerald
<br />
<br />Last.
<br />White
<br />
<br />Suffix)
<br />
<br />
<br />4. CITY AND STATE DR TI:RRITDRY. DR FOREIGN COUNTRY OF BIRTH
<br />Wood River. Nebraska
<br />
<br />5a. AGE-Last Birthday
<br />(Yrs.) 75
<br />
<br />6. DATI: OF BIRTH (Mo.. Day, Yr.)
<br />
<br />April 12, 1932
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />505-36-4089
<br />
<br />8a. PLACE OF DEATH
<br />!ill.S.f'.1IAj.: ~ _I~pali~nt
<br />
<br />QTHEB: 0 Nursing Home/LTC 0 Hospice FaCility
<br />
<br />8b. FACILITY.NAME (If not Inslllullon, give slreel and numDet)
<br />
<br />o ER/Oulpatlenl
<br />
<br />o DecedBnt's Home
<br />
<br />St. Francis Me~ical Center
<br />
<br />Oro>.
<br />
<br />o Olher (Specily)
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />8d. COUNTY OF DEATH
<br />Hall
<br />
<br />Grand Island
<br />
<br />68803
<br />
<br />9a. RESIDENCE.STATE
<br />Nebraska
<br />9d. STREET ANO NUMBER
<br />2017 S. Adams St.
<br />
<br />9b. COUNTY
<br />
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />Xl YES 0 NO
<br />
<br />Hall
<br />
<br />9f. ZIP CODE
<br />68801
<br />
<br />loa. MARITAL STATUS AT TIME OF DEATH 91: Marriod 0 Novor Marriod
<br />
<br />lOb. NAME OF SPOUSE (FlrSI. Mlddlo, Lasl, Sufllx) If wlfo, glvs maldsn name.
<br />
<br />o Mo"lod, butsoparated 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Roma J. McAhren
<br />
<br />11. FATHER'S.NAME (First, Middlo,
<br />_.li e S!~X ~._
<br />
<br />Last,
<br />White
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S-NAME (First, Middle. Maidon Surnamo)
<br />_______!:at:..~~~'". Brown
<br />., ~'_.'.~--l-.~..-"~'..
<br />l4b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />13, EVER IN U,S, ARMED FORCES? Give detes of service If yes. l4e.INFORMANT.NAME
<br />(yeY:fof't,;JM2/1952 6/1/1954 Roma White
<br />
<br />15. METHOD OF DISPOSiTION
<br />
<br />~urial 0 Donetion
<br />
<br />o Cremation (J Entombmont
<br />
<br />
<br />1 6b. LICENSE NO
<br />"15;Zr
<br />
<br />16c, DATE (Mo.. Day, Yr. )
<br />September 8. 2007
<br />
<br />CITY I TOWN STATE
<br />
<br />o Removal 0 Olher (Specify)
<br />
<br />Westlawn Memorial Park Cemetery, Grand Island, NE.
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City Or Town, Stato)
<br />Apfel Funeral Home. 1123 West Second,
<br />
<br />Grand Island. NE.
<br />
<br />1 7b. Zip Code
<br />68801
<br />
<br />18. PART l. Enter the Chain of BVBntsndiSBaSeS, injuries, or compllcatlons~-thal directly caused the death. DO NOT enter terminal $vent$ such as cardiac arrest,
<br />respiratory a"est, or ventricular flbrllletion without showing tho otiology. DO NOT ABBREVIATE. Enter only one ceuse on e line. Add eddltionalllnes if necessery.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />onset to death
<br />
<br />[, 0' I(A ,~".,'~_,......u_
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl..... or ocndltlon resulting
<br />In death)
<br />
<br />(a) C I<A.~,~O~
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I onsaf to death
<br />I
<br />I
<br />_J...
<br />I
<br />I
<br />I
<br />I
<br />
<br />OJJE'1C4A
<br />
<br />,f,-
<br />
<br />Soquontlalfy 1I0t conditions, II
<br />any, leading to lhe cauaellsted
<br />on IIn08.
<br />EnhlrtheUNDERLYINGCAUSE
<br />(dls..se or Injury thet Inlllotod
<br />the ovonts resulting In death)
<br />I.ASI"
<br />
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />(e)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to tho doath but not rosulling in the underlying cause given In PART I,
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES 0 NO
<br />
<br />CaPO
<br />
<br />20, IF FEMALE:
<br />o Not pregnant within past yoar
<br />o Pregnent at time of deelh
<br />o Not pregnant, but pregnant within 42 days of doath
<br />(J NOI pregnent, but pregnanl 43 days 10 1 yeer belore death
<br />J:l !Jnknown jf pr8~n~.l1t wit~i~ the p.Q~13a......
<br />
<br />~la. MANNER OF DEATH
<br />~etural 0 Homicide
<br />
<br />o AccldontO Pending Investigation
<br />
<br />o Sulcido 0 Could not be determlnsd
<br />
<br />21 b. IF TRANSPORTATION INJURY
<br />o Drivor/Oporator
<br />
<br />o Passenger
<br />
<br />o Pedestrian
<br />
<br />o Other (Specify)
<br />
<br />~lc. WAS AN AUTOPSY PERFORMED?
<br />DYES ,l,NO
<br />
<br />~ld. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES NO
<br />
<br />~~d.INJURY AT WORK'
<br />
<br />
<br />2~e. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />~~b_ TIME OF INJURY ~~e. PLACE OF INJURY-AI home, ferm, street, factory, office building, conslrucllon silo, otc, (Specify)
<br />m
<br />
<br />(J YES 0 NO
<br />
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />~4a. DATE SIGNED (Mo.. Dey, Yr,)
<br />
<br />24b. TIME OF DEATH
<br />
<br />z>
<br />.t~!l!
<br />I ill a:
<br />fS~
<br />eg~~
<br />1i~::>
<br />~ii:8
<br />Ok
<br /><.l 0
<br />
<br />m
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo.. Dey, Yr.) 24<1. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24B. On the basis 01 examination and/or investigation, in my opinion death occurred at
<br />the lime, dete and piece and due to Ihe ceuse(s) statod. (Signaluro and Titlo) T
<br />
<br />26a, HAS ORGAN OR TiSSUE DONATION BEEN CONSIDERED? ~6b. WAS CONSENT GRANTED?
<br />
<br />__~~s._O N<?~P_R_~B~BL~ 0 UNKNOWN 0 YES NO Not Appliceble_~!~~ls_f!.?_ 0 YES ~NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typo or Print)
<br />David Colan M.D. 729 N. Cust r Ave. Grand Island. NE. 68803
<br />
<br />
<br />26a, REGISTRAR'S SIGNATURE 26b, DATE FILED BY REGISTRAR (Mo.. Dey, Yr.)
<br />
<br />SEP 1 2 2007
<br />
|