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<br />I
<br />"\J
<br />
<br />
<br />1,DECEDENT'S-NAME (FirSI,
<br />Stephen
<br />
<br />STATE OF NEBRASKA
<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 />:::;::~~:::::;TORY FOR VITAL RECORDS. _#61. '.".....i", '/"",1.' . ~ ~....,'_.: 'ffl.,:,:.: ,
<br />
<br />"""-'" J,lfANL:t.YJ/. .ctoqfE~_
<br />OCT 1 6 Z007 2 0 0 8 0 0 6 3 4 As$ISiCANt~T1iTE REGi~AR.
<br />LINCOLN, NEBRASKA HEAU74 ~ND HUMAN sE"'AVrf"€s J;:,
<br />.::: ,~~':,:' '<.l ~r : ::,,:, <-
<br />...... _ I", 1 ~ ''.<If .l~..l...-J :..-
<br />,.,:: ...........
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE'AND SUPP ,~.
<br />Octol?er 16. 200L_ C_ERTIFJCAT~ OF DEATH 'f ........ . :85 45
<br />,I ~.- "'..... if. 0;
<br />2, SEX t. '''' 3 DATJ; of V ATK [Mo, Day, Yr)
<br />Male. " -8'e'pt-ember 27.2007
<br />
<br />5a_ AGE-L.st Birthday 5b, UNDER 1 YEAR 5c, UNDER 1 DAY 6, DAYE OF BIRTH (Mo" Day, Yr_)
<br />(Yrs,) MOS, DAYS HOURS MINS_
<br />
<br />Middl.,
<br />Terrell
<br />
<br />Last,
<br />Fleharty
<br />
<br />SuffiX)
<br />Sr.
<br />
<br />~
<br />
<br />\
<br />
<br />Amended
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Trumbull. Nebraska
<br />
<br />93
<br />
<br />March 22. 1914
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />587 16 4638 507-16-4637
<br />
<br />ea. PLACE OF DEATH
<br />l:IQSflIAl: 0 Inpatient
<br />
<br />QII;Jf8: 00 Nursing Home/LTC 0 Hospice F.cility
<br />
<br />Bb, FACllITY.NAME (If not institution, give street and number)
<br />
<br />Good Samaritan rCenter
<br />
<br />(J ER/Outpatient
<br />
<br />o Decedent's Home
<br />
<br />Be, CITY OR TOWN OF DEATH (Include Zip Code)
<br />Wood River
<br />
<br />68883
<br />
<br />-~al_~
<br />
<br />o CO\ 0 Other (Specify)
<br />
<br />...~~:11ATH,
<br />
<br />90_ CiTY OR TOWN
<br />Wood
<br />
<br />9.. RESIDENCE-STATE
<br />Nebraska
<br />
<br />o M.rried 0 Never Merri.d 10b_ NAME OF SPOUSE (First, Middl., L.st, Suffix) If wife, give meidsn neme,
<br />
<br />
<br />91. ZIP CODE
<br />68883
<br />
<br />9g, INSIDE CITY LIMITS
<br />
<br />~ YES 0 NO
<br />
<br />St.
<br />
<br />o Divorced 0 Unknown
<br />
<br />Middle,
<br />
<br />L.st, SUffl')
<br />Fleharty
<br />
<br />12_ MOTHER'S-NAME (First,
<br />Etta
<br />
<br />Middle,
<br />May
<br />
<br />Maiden Surname)
<br />Bishop
<br />
<br />13, EVER IN U,S, ARMED FORCES? Give dates of service if yes, 14., INFORMANT-NAME
<br />(Yes, no, or unk) No Stephen T.
<br />15 METHOD OF DISPOSITION r6. EMBALMER-SIGNATURE
<br />08uri.1 o Donallon Not Embalmed
<br />"'.~,,, 0 _._ - ",. c,,=~..c,,~ro~ ,eo,""~ =.""
<br />
<br />o Remov.1 o Other (Specify) Westlawn Memorial
<br />
<br />-- ----
<br />17e_ FUNERAL HOME NAME AND MAILING ADDRESS
<br />Apfel Funeral Home.
<br />
<br />Fleharty Jr.
<br />
<br />I=ENO
<br />
<br />CITY / TOWN
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Son
<br />
<br />/ 16c. DATE (Mo" D.y, Yr.)
<br />September 28. 200
<br />
<br />STATE
<br />
<br />Park Crematory
<br />
<br />Grand NE
<br />
<br />PART I. Enter the chain 01 p.Np.nl!o--diseasBs, injuries, or complicationsuthat directly causad the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory .rrest, or ventricular flbrill.tion without showing the etiology, DO NOT ABBREVIATE. Enter only one cause on a line, Add .dditlonallines if necess.ry_
<br />
<br />(a)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />_l\\~"^'<\Vj-w~ ~~_~
<br />\)-x.
<br />
<br />onSet to death
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl_. or oondftlon resulting
<br />In dealh)
<br />
<br />S.qu.ntlally list condlllon., If (b) t.. \. '(l,N\. ~c.. t ~"" 'rtN t\:\ u...... \~
<br />sny, leading to thee,us.lIsted ------ouE-To;-ORAS A CONSEQUENCE OF:
<br />onlinl!l'.
<br />Enfllrthe UNDERLYING CAUSE
<br />(dl..... or InJurylhallnltl.l9d (c)
<br />tlla ev.ntl resulling in death)
<br />LAST
<br />
<br />__ ~,\ru
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />'f t,tW\.\
<br />
<br />onset to d..th
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to deelh
<br />
<br />(d)
<br />
<br />PART II, OTHER SiGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying C.use given in PART I,
<br />
<br />~CJJ ~
<br />
<br />19, WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />DYES
<br />
<br />o NO
<br />
<br />20, IF FEMALE: 21._ MANNER OF DEATH 21 b_IFTRANSPORTATlON INJURY 21c, WAS AN AUTOPSY PERFORMED?
<br />(J Not pregnant within past ye.r ')(Nalur.1 0 Homicide CI Driver/Operator
<br />
<br />o Pregnant at lime of de.th 0 AccidentO Pending Inv.stig.tion 0 Passenger
<br />
<br />o Not pregnant, but pr.gnent within 42 days of d..lh 0 Suicide 0 Could not be det.rmined 0 Pedestrian 21 d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Not pregnant, but pregnant 43 d.ys to 1 year before death 0 Other (Specify) COMPLETE CAUSE OF DEATH?
<br />o Unknown If pregnant within the p.st ye.r 0 YES 0 NO
<br />
<br />- 22a DATE OF IN~RI ~ ' Day, Yr) J~b TIME OF INJUR: -2-2C PLACE OF INJURY.At ham., f.rm street, tactory, of lice bUilding, construction site, ele (SpeCify)
<br />
<br />22d INJURY A-;:WORK;~D-ESCR-IBE HOW INJURY OCCURRED
<br />DYES ONO __I
<br />
<br />22f, LOCATION OF INJURY - STREET & NUMBER, APT. NO_
<br />
<br />DYES
<br />
<br />~O
<br />
<br />~
<br />
<br />CITY/TOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a, DATE OF DEATH (Mo" Day, Yr,)
<br />
<br />24a, DATE SIGNED (Mo" Day, Yr,)
<br />
<br />24b_ TIME OF DEATH
<br />
<br />z>
<br />1iS~
<br />'llllla:
<br />H~
<br />c.A.. iI( ~
<br />~~t~
<br /><>wz
<br />llz=>
<br />,2~8
<br />8 II
<br />
<br />m
<br />
<br />24e. PRONOUNCED DEAD (Mo" D.y, Yr.) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e, On the basis of examination and/or investigation, in my opinion death occurrEld al
<br />the time, date and place and due to the causers) steled, (Si9n.ture and Title) "
<br />
<br />DYES '\lI.,NO _0 PROBABLY CI UNKNOWN 0 Y_E? ~O
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type Or Print)
<br />Steven Husen M.D. 2116 West Faidley Ave.. Grand
<br />
<br />2ea_ REGISTRAR'S SIGNATURE
<br />
<br />26b, WAS CONSENT GRANTED?
<br />Not Applic.bl~_i.!..2,6. is NO 0 YES ~~.~
<br />
<br />
<br />Island. NE.
<br />
<br />68803
<br />
<br />28b, DATE FILED BY REGISTRAR (Mo" Day, Yr,)
<br />
<br />OCT 3 2007
<br />
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