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<br />2008UU3::14
<br />
<br />..
<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 ORIGlNAJ;..REC.6JrVdi-3!JLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL sTI!if$T!CS-SEcrij:JN,.:WltICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~,~'f:..'"....-.'."..-~_-.'-'.: . -' '1..-.- '.'~. '.i!r~.~2"=..'"
<br />
<br />DATE OF ISSUANCE .7 ,.... (11. ~
<br />DEe 2 1 2006 >,: '" ,-- TANtEYB. POOi!ER
<br />1isSfSTANT STATE RltGiStRAR
<br />LINCOLN, NEBRASKA H(~LTR-ANtJ HJ!~A/'I'sE&iCEs
<br />
<br />--
<br />--
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPOR"O 6
<br />.____ CERTIFICATE OF DEATH _ '__
<br />
<br />33867
<br />
<br />DECEDENT'S-NAME (Flrsl,
<br />James
<br />
<br />Middlo,
<br />
<br />Lasl,
<br />
<br />Suffix)
<br />
<br />2. SEX
<br />
<br />Male
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE.Lasl Blrlhday
<br />(Yrs.)
<br />
<br />103
<br />
<br />50. UNOER 1 YEAR
<br />MOS. OAYS
<br />
<br />50. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />3. DATE OF OeATH (Mo., Osy, Yr.)
<br />December 11, 2006
<br />6. DATE OF BIRTH IMo" Oay, Yr.)
<br />
<br />S
<br />
<br />Morton
<br />
<br />Hamilton County, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506-44-2026
<br />
<br />November 08,1903
<br />
<br />Ba. PLACE OF OEATH
<br />!:!.Q.SEJIAJ.:
<br />
<br />o Inpstlent
<br />
<br />QIHER: ~ Nursing Home/LTC Ll Hospice Facility
<br />
<br />8b. fACiL:TY~NAME (1f Po"l !fls1ltulion, gIve 5treel and l'\umbtH)
<br />
<br />o ER/Outpalienl
<br />
<br />W O.c.d.nt's Home
<br />
<br />Good Samaritan Care Center
<br />
<br />OM
<br />
<br />o Oth.r (Specify)
<br />
<br />BC. CITY OR TOWN OF OEATH (Include Zip Code)
<br />
<br />Wood River
<br />
<br />Bd. COUNTY OF OEATH
<br />Hall
<br />
<br />ge. RESIOENCE-STATE
<br />Nebraska
<br />
<br />._~J90'c;~t----
<br />
<br />e.CITY~T~~~~~iver
<br />"'-~_9. AP~_:.J 9f.ZIPCO::883
<br />
<br />lOb. NAME OF SPOUSE (First, Middle, Lasl, Sutfix) If wlf., glv. m.ld.n name.
<br />
<br />-'--..-.-l~IDE CITY LIMITS
<br />L1: YES 0 NO
<br />-" ".,',-"'-..--.....-
<br />
<br />9d. STREET AND NUMBER
<br />1401 East Street
<br />
<br />lOa. MARITAL STATUS AT TIM I:' OF DEATH 0 Married 0 Nev.r Marrl.d
<br />
<br />[J Married, but separated !SWldowed 0 Olvorc.d 0 Unknown
<br />
<br />Jane Ellen Torgerson (Dec'd)
<br />
<br />11. FATHER'S.NAME (First,
<br />John
<br />
<br />Middle,
<br />
<br />L.st, Suffix)
<br />Morton
<br />
<br />12. MOTHER'$.NAME (Flrsl,
<br />Jessie
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />Boag
<br />
<br />13. EVI:'R IN U.S. ARMEO FORCES? Give deles of s.rvlce If yes.
<br />(Y.s, no, or unk~O
<br />15. METHOD OF DISPOSITION
<br />~urial 0 Donation
<br />
<br />14a.INFORMANT.NAMI:'
<br />Robert Morton
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />
<br />o Cremation 0 Entombment
<br />
<br />
<br />-.<.~ .LL.
<br />MATORY OR OTHER LOCATION
<br />
<br />__t~~~~;~ NO-----
<br />
<br />CITY /TOWN
<br />
<br />16c. OATE (Mo., Oay, Yr. )
<br />December 15, 2006
<br />
<br />STATE
<br />
<br />o Romoval 0 Olher (Sp.clfy)
<br />
<br />Case Cemetery
<br />
<br />Giltner Nebraska 68841
<br />
<br />PART I. Enter the chaIn of evenlsudlseases, Injuries,' or compllcallons--thal directly caused the death. DO NOT enter terminal events such as ea.rdlac arrest,
<br />respiralory .rresl, or ventrlculer Ilbrlflalfon without Showing Iho otiology. DO NOT ABBREVIATE. Enter only one cause on a IIn.. Add eddltionalllnes If necessary.
<br />IMMEDIATE CAUSE:
<br />
<br />
<br />17a. FUNERAL HOME NAME AND MAILING AOORESS (Slreel, Clly orTown, SI.le)
<br />Higby-McQuiston Mortuary, P.O. Box 204, Aurora, NE, 68818-0204
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />dl..... or oondltlon r..ultlng
<br />In death)
<br />
<br />(.) m L<-1.H~.s~ s+e-m
<br />~UE TO, OR AS A CONSEQUENCE OF:
<br />
<br />- :~ETfo~~f66~sfQ~~E OF: CLj ~
<br />
<br />feU. 1,-<- r ~
<br />
<br />I
<br />,
<br />,
<br />I
<br />,
<br />....I.
<br />,
<br />
<br />mOr] i-hs
<br />
<br />Mse110 death
<br />
<br />onsello death
<br />
<br />Sequ.ntlally ti.1 oondltlon., If
<br />any, leading to the c.u.oll.ted
<br />on line 8.
<br />Ent.rthe UNOERLYING CAUSE
<br />(dl..... or Injury th.t Inltl.t.d
<br />the .v.nt. r..ultlng In d..th)
<br />lASr
<br />
<br />.____;~_!:1 ears
<br />
<br />, on..lto d.alh
<br />,
<br />,
<br />
<br />(c)
<br />
<br />DUETO,ORASACONSEQUENCEOF: II / z lJt'i/}1 t'r 5 dt""lJ?r&'n h ',a, (i})t-tJli<
<br />
<br />(d) derC-DrtJ Vd'f,Cuh'lr djS.edS~1 a";"llef'~se/el"'~ I--/i:--
<br />CCJr&/)6l~-bId2:S(!l. .. .
<br />16. PART II. OTHI:'R SIGNIFICANT CONDITIONS.Condillon~nlribUtlng 10 Ih. d.ath but nol resulting in I e Un er y ng causo givon In PART I.
<br />
<br />onsollo d.alh
<br />
<br />19. WAS MEOICAL EXAMINER
<br />
<br />20. IF FEMALE: N / A 21~NER OF DEATH 21b.IFTRANSPORTATION INJURY 210. WAS AN AUTOPSY PERFORMED?
<br />o Not pregn.nl wilhin pas/y~ar ANalural [J Homicide 0 Driver/Operator 0 YES XNO
<br />[J Pregnenl alllm. of dealh 0 AccldenlW P.ndlng Investlg.tion 0 Passenger .. ,._......M_. .... _ __._.
<br />
<br />o Nol pr.gnanl, bul pr.gnant within 42 deys 01 death 0 Suicide 0 Could nol be dolermined 0 P.destrian 21d. WERE AUTOPSY FINOINGS AVAILABLE TO
<br />o Not pregnanl, bul pregnanl43 days 10 1 year before dealh 0 Olh.r (Specify) COMPLETE CAUSE OF OEATH?
<br />'"i 0 Unknown If p,egnanl within the past year __ ______._ .., 0 YE~..__.._g_NO .. j.,t!].
<br />~; ~"'22li. OATI:' OF INJURY TfJ'o., iJay, vi.) . 22b. TIME OF INJURv-- 220. PLACE OF INJURY-At home, '.rm, street, f.ctory, office building, conatructlon slle, elc. (Speclty)
<br />
<br />--22d~'NJURyIj1~? 22~~DESCRIBE HOW INJURY OCCU;REO . _.._.o..w.__.__
<br />
<br />OR CORONER CONTACTED?
<br />o YES _-,{f}_..o___,
<br />
<br />o YES 0 NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CrTYlfOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo., Dey, Yr.)
<br />December 11
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />23c. TIME OF DEATH
<br />
<br />:s~~
<br />'\lUla:
<br />'!j>Q
<br />c.if~~
<br />~~~~
<br />"z=>
<br />"'00
<br />~a:c.>
<br />815
<br />
<br />m
<br />
<br />2006
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />
<br />24d. TIME PRONOUNCEO OEAO
<br />m
<br />
<br />248. On the basis of examination and/or investigation, in my opinion death occurred at
<br />Ihe time, det. .nd place end due 10 the c.us.(s) stated. (Slgnalure and Title) '"
<br />
<br />,-
<br />25. DiD TOBACCO USI:' CONTRIBUTI:' TO THE DI:'ATH?
<br />
<br />o YES ~O __!::-!!ROBABLY Ll_ UNK_~O\'l~..._....9.!~~_____ NO
<br />27. NAME, TITLE AND ADDRI:'SS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Prlnl)
<br />steve Husen, M.D. 2116 W Faidle Suite 400
<br />
<br />26b. WAS CONSENT GRANTED?
<br />Nol Applicable if 26a Is NO 0 YES 'ii" NO
<br />
<br />Grand Island
<br />
<br />NE 68803
<br />
<br />26a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. OATE FILEO BY REGISTRAR (Mo., Oey, Yr.)
<br />
<br />DEe 2 0 2006
<br />
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