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<br />1, DECEDENT'S.NAME (Firsl,
<br />Helen Lucille McCown
<br />
<br />STATE OF NEBRASKA
<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 STATI$TI,C!i::.~JfJN.)4'!J'CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. '~i.~~-'-::l=' It:.;;;,,~t:., .
<br />
<br />DATE OF ISSUANCE ~i!;~~ '
<br />
<br />JUN 2 0 2007 2 0 0 7 0 8 7 0 9 ASSISTANQWi'iiEQIStfiAi ", J
<br />LINCOLN, NEBRASKA HEA1.Tii)vl"b'ffUMANSERYicES'-
<br />:_~ -r_: _I ~- .:::: =..:"
<br />_n ~' _, ," ~ -:-"".
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINAN~~A,., N,~,;,"~"" - ',,' ~,:",,---,~,~,:ij,,,,~~ ':J, ' lZ ,-'7'
<br />CERTIFICATE OF DEATH -. : .;:::lJ~'fC7;"C'4P ~
<br />2, SEX -0-'0,; ,j.DA'rE 6F'~H (Mo" Day. Yr,)
<br />Female uMaY31, 2007
<br />
<br />.
<br />
<br />Middle.
<br />
<br />La.t,
<br />
<br />Suffix)
<br />
<br />4, CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a, AGE-Last Blrlhday
<br />(Yrs,)
<br />
<br />5b. UNDER 1 YEAR
<br />MOS, DAYS
<br />
<br />5c, UNDER 1 DAY
<br />HOURS
<br />
<br />6, DATE OF BIRTH (Mo.. Day, Yr,)
<br />
<br />Oconto, Nebraska
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />
<br />80
<br />
<br />
<br />8a, PLACE OF DEATH
<br />
<br />
<br />508-28-0787
<br />
<br />~:
<br />
<br />D Inpatienl
<br />
<br />Qll:!ER 0 Nursing HomelL TC D Hospice Facility
<br />
<br />Bb, FACILlTY.NAME (II not In.tltutlon. give str..t and number)
<br />
<br />D ER/Oulpallent
<br />
<br />iii Decedent'S Home
<br />
<br />;
<br />
<br />413 N. Cleburn
<br />Bc, CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />Grand Island 68801
<br />9a, RESIDENCE-8TATE
<br />
<br />P-lD.'
<br />
<br />D Other S .cl
<br />
<br />...
<br /><(
<br />II:
<br />!;\!
<br />[i!
<br />i
<br />'l.'I
<br />
<br />~
<br />12
<br />ti
<br />'ll.
<br />E
<br />8
<br />t!
<br />{i
<br />
<br />Bd. COUNTY OF DEATH
<br />
<br />91. ZIP CODE
<br />
<br />68801
<br />
<br />10b, NAME OF SPOUSE (Flrsl. Middle. Last, SutJIx) It Wile. give maiden nam.,
<br />
<br />
<br />9g, INSIDE CITY LIMITS
<br />
<br />IJI YES D NO
<br />
<br />91), COUNTY
<br />
<br />Nebraska
<br />9d, STREET AND NUMBER
<br />
<br />413 N. Cleburn
<br />lOa, MARITAL STATUS AT TIME OF DEATH D Marrl.d D N.v.r Ma",ed
<br />
<br />Hall
<br />
<br />D Marned, bul separaled 0 Widowed 00 DIVorced D Unknown
<br />
<br />15. METHOD OF DISPOSITION
<br />~Burlal D Donation
<br />D Cremation D Enlombmenl
<br />D Removal D Other (Sp.Clfy)
<br />
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Dau hter
<br />16C. DATE (Mo.. Day, Yr. )
<br />June 5, 2007
<br />STATE
<br />
<br />11. FATHER'S-NAME (Firsl,
<br />Claus Hanson Buck
<br />f3. EVER IN U.S, ARMED FORCES? Give dat.e 01 service II yes.
<br />(Yes. no. orunk.) No
<br />
<br />Middle,
<br />
<br />Lasl,
<br />
<br />SuUlx)
<br />
<br />(First,
<br />
<br />Mlddte.
<br />
<br />Malden Surname)
<br />
<br />Wesllawn Memorial Park Cemetery
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clly orTown, Slat.)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />
<br />17b, Zip Code
<br />68801
<br />
<br />CAUSE OF DEATH (See Instructions and examples)
<br />lB. PART I. Enler Ihe chain ol.vents--dls.a.... Injurf.., or compllcatlons--Ihat directly ceused the deelh. 00 NOT enler terminal events euch as cardiac a"es~
<br />respiratory a".sl, orv.n~tcular Rbrfllallon without showing the etiology, 00 NOT ABBREVIATE, Enter only one cau.. on a line. Add addlllonal lines II necessary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />on..1 10 dealh
<br />
<br />IMMEOIATECAUSE (Fhal
<br />d..... or condllon rllllftl"",
<br />h death)
<br />
<br />(a)
<br />
<br />
<br />
<br />Saquenllally lIalcondlllont, W (b)
<br />any,laadlnglothacaullllalad DUE TO, OR ASA CONSEQUENCE OF;
<br />on linea.
<br />Enter Iha UNDERLYING CAUSE
<br />(dtse..e or tn/Ul'( that Inlttated (C)
<br />theevenlllrosullngndealh) DUE TO, OR ASA CONSEQUENCE OF:
<br />IASr
<br />
<br />onsel to death
<br />
<br />onset 10 dealh
<br />
<br />(d)
<br />
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES 1Il NO
<br />
<br />II:
<br />l&l
<br />~
<br />Ii;
<br />l&l
<br />CJ
<br />i
<br />a:
<br />
<br />..1-
<br />al
<br />{J.
<br />
<br />20. FEMALE:
<br />
<br />
<br />9"NOI pregnant wllhln past year
<br />
<br />D Pregnant at lime 01 dealh
<br />
<br />
<br />D Not pregnant, but pregnant wlthln 42 days 01 deall1
<br />
<br />D Nol pregnanl. but pr.gnant43 days to 1 yearbelore death
<br />
<br />D Unknown II pregnanl within th. pasl year
<br />
<br />D YES ~O
<br />
<br />o AccidenlD Pending Investigation
<br />D Suicide D Could not be delermlned
<br />
<br />21b, IF TRANSPORTATION INJURY
<br />o Drfver/Operator
<br />
<br />D pass.nger
<br />
<br />D P.d..lrfan
<br />
<br />D Oll1er (SpeClly)
<br />
<br />21 c. WAS AN AUTOPSY PERFORMED?
<br />
<br />2fd, WERE AUTOPSY RNDIN<.iS AVAILABLE TO
<br />
<br />COMPJ.ETE CAUSE OF DEATH?
<br />DYES p-No
<br />
<br />. th, DATE OF INJURY (1.10,. Day, Yr.)
<br />
<br />22b. TIME OF INJURY 220. PLACE OF INJURY.At home, larm. .lre.l. lactory. omoo building, oonslRlcUon slle, olc. (Spectfy)
<br />m
<br />
<br />22d.INJURY ATWORK? 220. DESCRIBE HOW INJURY OCCURRED
<br />DYES ~
<br />
<br />221. LOCATION OF tNJURY - STREET & NUMBER. APT. NO.
<br />
<br />CtTVITOWN
<br />
<br />S1l\TE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo.. Day, Yr.)
<br />May 31, 2007
<br />
<br />24a. DATE SIGNED (Mo.. Day. Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />~~~
<br />i~~
<br />:i :d: >-
<br />a.G.. C; ...J
<br />E... >- z
<br />oa:t-o
<br />UIUZ
<br />"Z:>
<br />~~8
<br />80
<br />
<br />m
<br />
<br />
<br />23c. TIME OF DEATH
<br />11 :50
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day. Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24.. On Ihe basis 01 exarnlnation and/or investigation, in my opinion death occurred at
<br />Ihe lime, dale and place and due to Ihe cause(s) stated. (Signature and Tille) T
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />A
<br />
<br />DYES D PROBABLY D UNKNOWN 0 YES 0
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Phnt)
<br />Ryan Crouch, D.O., 800 .l.lpha Street, Grand I
<br />
<br />4u1tltJ 1.
<br />
<br />Not Applicable il28a is NO D YES
<br />
<br />
<br />2Ba. REGISTRAR'S SIGNATURE
<br />
<br />
<br />
<br />2Bb. DATJUN BIRE'r2~d7Mo. Day. Yr,)
<br />
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