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<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 />::~:~::::N:;ORY FOR WTAL RECOROS ~~~ER
<br />fEB 2. 7 2008 2 0 0 8 0 2 5 2 6 ASSISTANT ~..~.I.mJ........ .~. O. 18ll!.lA. ,JR R, .
<br />LINCOLN, NEBRASKA HEALTH -AN.P.HUfiAN'$EIt~
<br />".~ I,~"\~:-, ~.~'.."<' ~_
<br />
<br />
<br />"^"'" '''RA''^-D'''"';~;;,~rF~~~~F"~~A~:f'C'' "".,,,,,~~i~f ~~i~~;
<br />
<br />1. DECEDENT'S.NAME (Fi~~~:-~. Middle, La.t, Sultix) 2. SEX t..g:ti#fQF,~~T~ l(>\ll~'J)ay~)
<br />ltil.dred J. Judkins Femal.e ,F~~ }20- ;~l.I~Q'
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 50. AGE.Last Birthday 8" DA~E QSlllRT~.llii,,:: Day, T;.)
<br />(Yr..)
<br />
<br />McCool. Junction, Nebraska
<br />
<br />86
<br />
<br />
<br />May 17, 1921
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />506-24-8122
<br />
<br />lIS. PLACE OF DEATH
<br />!:lOSflIAL: B Inpalient
<br />
<br />0Jl:jfB: 0 Nursing Homoll.TC 0 Hospice Fecllity
<br />
<br />8b. FACILITY.NAME (If not inatitution, give atreet and number)
<br />
<br />o ERlOutpatlBnt
<br />
<br />Q Decedent's Home
<br />
<br />SairitYrancis Medical. Center
<br />
<br />- ~~~""""'~~-
<br />
<br />o roo.
<br />
<br />o Ctner (Specify)
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island, 68803
<br />
<br />80. COUNTY OF DEATH
<br />Hall
<br />
<br />.~
<br />
<br />!lb.COU~
<br />Hall
<br />
<br />
<br />9/, ZIP CODE
<br />68801
<br />
<br />9g.INSIDE CITY LIMITS
<br />BYES 0 NO
<br />
<br />o Married 0 Never MarrIed 1 Ob. NAME OF SPOUSE (First. Mlddlll. L.asl, Suffix) If wife. give maiden name.
<br />
<br />o Married, bUl separated 0 Widowed ]lDivoroed 0 Unknown
<br />
<br />11. FATHER'S.NAMe (First,
<br />Richard
<br />
<br />Middle,
<br />D.
<br />
<br />Last, Sulllx)
<br />Matthews
<br />
<br />12. MOTHER'S.NAME (Flrsl,
<br />Helena
<br />
<br />Middle,
<br />A.
<br />
<br />Melden Surname)
<br />Menke
<br />
<br />1S. EVER IN U.S. ARMcO FORCES? Give date. 01 service il ye.. 14a.INFORMANT.NAMe
<br />(Yes, no, or unk.) No Rose Judkins
<br />15. METHOD OF DISPOSITION
<br />o Burial 0 Donelion
<br />BCrematlon 0 Enlombment
<br />o Removal
<br />
<br />CITY I TOWN
<br />
<br />14b. RELATIO~lSHIP TO DECEDENT
<br />Daughter
<br />
<br />160. DATE (Mo., Day, Yr.)
<br />Fab 22, 2008
<br />
<br />STATE
<br />
<br />
<br />16b. LICENSE NO.
<br />1092
<br />
<br />Central Nebr. Cremation Servic G~on
<br />
<br />NE
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Slete)
<br />CUrran Fun.ral Chapel 3005 South Locuet
<br />
<br />HE
<br />
<br />
<br />PART I. Enter the ~1.Jt'enjS..di.aasas, injuriss, Or complicetion...lhal directly caused Ina deatn. DO NOT .nler terminal events suoh as cardlao aneal,
<br />I.ep"alory arreel, 01 v.nllicuI6rllDrill.~dn Without .nowlng tne etiology. 00 NOT ABBRE1IIATE: Enlironly ona cou.,; on olin.. Add addltlonalllna.1I nace..ary.
<br />
<br />IMMEOIATE CAUSE:
<br />
<br />tMMEDIATE CAUSE (Flnat (a) C lJ)x~~r\.t::, ()., \( (" ~
<br />d1.....orcondlllon...U!Ung DUE TO, OR AS A CONSEQUENCE OF;
<br />In deaIh)
<br />
<br />SoquentlellytlatCOndltlona,If (b) ~
<br />.ny,leadlngtolhe"".",,llated DUErO.ORA!<"AC EOUENCEOF:
<br />on lint.. "-
<br />EnlerlneUNDERLYlNG CAUSE
<br />(dl..... 01 Injury thai Initiated (c)
<br />tha evems ....ulUng In death) . OUE TO, OR AS A CONSEQUENCE OF:
<br />lAST
<br />
<br />ansal to death
<br />
<br />'2/1\ [o1j
<br />
<br />onse1 to deat
<br />
<br />
<br />
<br />(0)
<br />
<br />-.----l
<br />
<br />18. PART II-OTHER]1 IF1CAN~ONDITIONs-cond[liOI'1S contributing to Ihe death but not rellutting in the underlying cause given In PART I.
<br />.(\, ..". I '
<br />~'\-Y7""__, \ -
<br />
<br />20. IF FEMALE:
<br />
<br />erNot pregnant within past year
<br />o Pregnanlat time 0/ death
<br />Q Not pregnant, but pregnant within 42 days of deGlh
<br />o Not pregnanl, but pr"llnanl43 days to 1 yaar belora ~aath
<br />o Unknl}wn if pregna.nt within Ihe pa.SI year
<br />
<br />o AccldantD Panding Invasligatlon
<br />
<br />21 b.IF TRANSPORTATION INJURY
<br />o Drluar/Operator
<br />
<br />o passaeger
<br />
<br />o Pedestrian
<br />
<br />19. WAS MEDICAL eXAMINER
<br />OR CORQNER CONTACTED?
<br />
<br />o YeS III NO
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />21a.MANNER OF DEATH
<br />]lNalural 0 Homlcida
<br />
<br />DYES IKNO
<br />
<br />o Suicide 0 Could not be determini:ld
<br />
<br />o Othar (Specify)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />Cl YES 0 NO
<br />
<br />DYES 0 NO
<br />
<br />
<br />22a. DATE OF INJURY (Me.. Day, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY.At horne, farm, slr..f, laclory. olliee building, conslrucUon aita, atc. (Specify)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY. STREET & NUMtlER, APT. NO.
<br />
<br />CITYITO\'vTo4
<br />
<br />STIITE
<br />
<br />ZIP CODE
<br />
<br />24a. OM E SIGNc;O 'iJiu., Op)", Yr,}
<br />
<br />N~. TIME OF OEATf<
<br />
<br />230. TIME OF OEATH
<br />9:14 am
<br />
<br />~~i:i
<br />lit
<br />~~~~
<br />1!~o
<br />~8~
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />248. On the basis of Rxamination and/or InvestigatIon, in my opinion death occurred at
<br />tna time, dete and piece end due 10 tne cause(s) slatad. (Signature and Tille) '"
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />o YES ~O 0 PROBABLY 0 UNKNOWN 0 YES K NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSiCIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Ryan D. Crouch 800 Alpha St., Grand Island, NE 68803
<br />
<br />Not Applicable if 28a ia NO 0 YES III NO
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />FEB 25 2008
<br />
<br />HH8-61 11/03 (55061)
<br />
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