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<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-SECIJON, WHICH IS
<br />
<br />:::;::~::::::~TORY FOR VITAL RECORDS. _ ':::;MI1Ir~~J~~
<br />
<br />FEB 0 9 2001' ie'- f'J~"7t;AN~~~$~OOPER
<br />2 0 0 8 0 0 7 5 0 AS:;lSr4~,~l'T*iIEqISTFlAR
<br />LINCOLN, NEBRASKA ~ HEAL;TflA.Nl), HUMlWf!FFlI(ICES
<br />- ,~" ,. <,' '..~\f\, .:';l-~:: -'- t::"
<br />
<br />STATE" OF NEBR" A, ,S, KA - DEPARTMENT O,F"HEALTH AND HUMANSERV, ICES FINANCE AND SUP,P"O~ .., "" 01 01 t'I"1
<br />. ___ CERTIF.~CATE OF DEATH ,_ H_~_
<br />
<br />1, DECEDENT'S.NAME (Flrsl, Middle, Last, Sulflx) 2, SEX 3, DATE OF DEATH (Mo" Day, Yr,)
<br />
<br />
<br />James w. Ni
<br />4, CITY AND STATE OR TERRITOR,Y, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />
<br />5a, AGHast 8irthd~; ~,CND, ER 1 YEAR
<br />
<br />(Yr.~ 6 t_.~os I-DAYS
<br />
<br />Ba, PLACE OF DEATH
<br />
<br />e,
<br />5c, UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />
<br />0-., 200-7-
<br />6, DATE OF BIRTH (Mo" Day, Yr,)
<br />
<br />Aug. 31, 1930
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />
<br />72') 07 292~ 727 07 2929
<br />FACILITY. NAME (If nol Inslilutlon, give slreet and number)
<br />
<br />!:!P~!'-'B.L
<br />
<br />o Inpalient
<br />
<br />01J-IEB: 0 Nursing Home/LTC 0 Hospice Fecllily
<br />
<br />o ERfOutpatlenl
<br />
<br />o Decedenl's Home
<br />
<br />St. Paul
<br />
<br />68873
<br />. -]9bco;:11
<br />
<br />o DY\ .ilolher(SpeCify) ~h1.gl1wl.!Y
<br />Bd, COUNTY OF DEATH
<br />Howard
<br />
<br />~}J:WY,,281.
<br />
<br />Bc, CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />--.--..-----,,&,-,- .~--,.. ...
<br />lOa, MARITAL STATUS AT TIME OF DEATH .Married 0 Never Merried
<br />
<br />[9C CITY OR TOWN -
<br />
<br />Wood River
<br />"' ~NO -191. ZIP COPE '[99 INSIDE CITY LIMITS
<br />
<br />hway 11 _~_n~_ I. 688_~_.____.~_YES ~ NO
<br />lOb, NAME OF SPOUSE (First, Middle, Lasl, Sulfix) If wife, give meiden nama,
<br />
<br />Nebraska
<br />9d, STREET ANP NUMBER
<br />12627 South Nebraska Hi
<br />
<br />o Married, bUI separated 0 Widowed 0 Plvorced 0 Unknown
<br />
<br />Cher J..l( Sewart . ....____
<br />11. FATHER'S-NAME (First, Mlddla, Lasl, Suffix) LI2'_M,O_,THER_.',S_ .NAME (FlrSRI, ac,',
<br />
<br />_<!qnas walter ]'i;i.Js;.kila ___
<br />13, EVER IN u,s, ARMEP FORCI'S? Givo datos of service If yeo, 14a,INFORMANT.NAME
<br />
<br />Middle, Maidon SUrnome)
<br />
<br />
<br />14b, RELATIONSHIP TO PeCEDENT
<br />
<br />tPI Burial
<br />
<br />o Ponallon
<br />
<br />Ch ri ikkil
<br />16a. Ff.\l;:\l~EfI;:SIGNATURE "1 ./S
<br />/~, ,>/';rt /1/ ,/",'a') _ /,#,." '
<br />i'" . /1/, #,dt"- i'''-' { ./ (,,,,,'f -rf)~~"f
<br />16d, CEMETERY, CREMATORY OR OTHER LOCATION ()'
<br />
<br />
<br />o Cremation U Entombment
<br />
<br />CITY f TOWN
<br />
<br />Wife..
<br />16c, DATE (Mo" Pay, Yr.)
<br />
<br />Jan 29_1.2007
<br />STATE
<br />
<br />(Yea, no, or unk.) rilo
<br />15, METHOP OF DISPOSITION
<br />
<br />o Removal 0 Olhor (Specify)
<br />
<br />Juniata Cemetery
<br />
<br />Juniata, Nebraska
<br />
<br />PART I. Enter the chain Qf-,~eUlS.--dlsea6es, InJuries, or complications--that directly oaused the death. DO NOT enter termInal evants such as cardiac arrest,
<br />respiratory arrasl, or venlricular fibrilla lion wlthoul snowing Ihe eliology, DO NOT ABBREVIATE, Enler only one cauSe on a line, Add addilionalllnes If necessary,
<br />
<br />
<br />Zip Code
<br />
<br />u... __.
<br />17a, FUNERAL HOME NAME ANP MAILING ADDRESS (Slreel, City orTown, SIalo)
<br />Jackson-Wilson Funeral Home=209
<br />
<br />IMMEPIATE CAUSE:
<br />
<br />onset 10 daalh
<br />
<br />IMMEDIATE CAUS~ (Final
<br />disease or condition resul1lng
<br />In deeth)
<br />
<br />(a) Ca:r:(hac Arrest
<br />PUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />immediate
<br />onset to death
<br />
<br />Sequenllallylist oondlllono,If ~_,Mas<:; 'fA TntArnal Injur.i E'5
<br />any, leading 10 the caUse listed DUE TO, OR AS A CONSEQUENCE OF;
<br />on line 8.
<br />~nt.r Iha UNDERLYING CAUSE
<br />(disease or Injury tnallnfUaled
<br />the events f8sultlng In death)
<br />L.ASf
<br />
<br />immediEl.te
<br />onset 10 death
<br />
<br />o Nol pragnant wltnin past year
<br />o Pregnant at lime 01 d.alh
<br />o Nol pregnanl, bUI pregnanl wilhln 42 days of dealh
<br />U Not pregnant, but pregnanl43 days 10 1 year before death
<br />o Unknown If pregn'!.nt within 11J.~~st \1dI__.,
<br />
<br />I oMelia dealh
<br />I
<br />(d) Car accident I immediate
<br />
<br />18 PART II OTHER SIGNIFICANT CONDITIONS-Condlllons conlrlbuIlng I~ the death but nol resulllng In Iho u~nd-Orly,"g cause given In PART:=Ilg- WAS MEDICAL EXAMINER
<br />OR CORON~R CONTACTED?
<br />
<br />Unknown pi: YES 0 NO
<br />-- ---
<br />21b,IF TRANSPORTATION INJURY 21C, WAS AN AUTOPSY PERFORMEP?
<br />o Privar/Operalor
<br />
<br />)llPasSengElf
<br />
<br />o Pedestrian
<br />
<br />o other (Specify)
<br />
<br />(c) Blunt impact to right side of body
<br />DUE TO, OR AS A CONSEQUENCE OF;
<br />
<br />immediate
<br />
<br />2 I a, MANNER OF PEATH
<br />o Natural U Homicida
<br />
<br />DYES
<br />
<br />)d.NO
<br />
<br />]i.ACCldentU Pending Invesligalion
<br />
<br />o Suicide 0 Could nol ba dolarmined
<br />
<br />21d, WERE AUTOPSY FINPINGS AVAILABLE TO
<br />
<br />COMPLETE CAUSE OF PEATH?
<br />a-YEs ~NO-
<br />
<br />DYES J&lNO
<br />
<br />
<br />22b, TIME OF INJURY 220, PLACE OF INJURY.AI home, farm, slraoUaclory, ofllce building, oonslrucllon site, etc, (Speolfy)
<br />-elH'- highway
<br />
<br />Passenger in car that lost control on snow-
<br />packed h.~ghway and collided with ?ncoming car
<br />
<br />1809
<br />
<br />m
<br />
<br />22a, PATE OF INJURY (Mo" Pey, Yr,)
<br />
<br />Ja.lluary 20,
<br />22d, INJURY AT WORK?
<br />
<br />221, LOCATION OF INJURY. STREET & NUMBER, APT. NO, CITYtTOWN
<br />Hw . 281 .9 mile soutn of St. Paul
<br />
<br />STPJE
<br />NE
<br />
<br />ZIP CODE
<br />
<br />6~~73
<br />
<br />23a, DATE OF DEATH (Mo" Pay, Yr.)
<br />
<br />24a, DATE SIGNEP (Mo" Day, Yr,)
<br />
<br />24b, TIME OF DEATH
<br />1809 m
<br />
<br />m
<br />
<br />z>
<br /><(W
<br />~-;;o
<br />ll~a:
<br />->~
<br />!if.~
<br />E _trI tZ
<br />8ffizo
<br />.8z=>
<br />~~8
<br />8~
<br />
<br />24d, TIME PRONOUNCED DEAD
<br />1809 m
<br />
<br />23b, DATe SIGNED (Mo" Pay, Yr.)
<br />
<br />23c, TIME OF DEATH
<br />
<br />23d, To the best of my knowledge, death occurred a1 the lime, dale and placB
<br />and due 10 Ihe causo(s) slalad, (Signature and Tillo) "
<br />
<br />How.Co.Att
<br />
<br />25, DID TOBACCO USE CONTRIBUTe TOTHE PEATH?
<br />
<br />Nol Applicable iI 26a Is NO 0 YES 0 NO
<br />
<br />P.O. Box
<br />
<br />
<br />28b, DATE FILEP BY REGISTRAR (Mo" Pay, Yr.)
<br />FEB 6 ZOO?
<br />
<br />~\
<br />
<br />28a, REGiSTRAR'S SIGNATURE
<br />
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