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<br />
<br />1. DECEDENTS.NAME (First,
<br />Thomas
<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUAjr' N SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECeF/D ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . . ..... /
<br />
<br />DATE OF ISSUANCE~J;g t/. )~~
<br />OCT 1 0 2007 ]V'"""" "aT4Niey~,tio.OPER
<br />2 0 0 8 0 2 5 9 " ASSISTA~~(~T1tt~"Rt;S/~TR.~R
<br />· HEALTir AND HUM,JlN SeRt4CES.
<br />,: :..~
<br />'",' ,:", Y'" 1.'"
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES~. ~C~Nt~. '~.r,. tl.t"l } O. 'iO'. 76 O'
<br />CERTIFICATE OF DEATH ',.r ....'" ..... .... .:.~
<br />'-Middle, LaSl. ..-- Sulfix) 2,SItX , '.::.: ,"1.' ~-~\:oF~1nr(MO"Day,Yr.)
<br />J. Brady Mal. ....'':.Mip~ 28, 2007
<br />1'- - -
<br />l1.pAT~OFBIRTH (Mo., Day, Yr.)
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />..
<br />
<br />4, CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE.Last Blrlhday
<br />(Yrs,)
<br />
<br />
<br />.;July 17, 1920
<br />
<br />8b. FACILITY-NAME (If not institution, give street end number)
<br />
<br />87
<br />1- B~ PLACE OF DEATH'
<br />tlO.SPJIAl..
<br />
<br />Slnpatiant
<br />
<br />Q]:!f8;
<br />
<br />a Nursing Home/LTC a Hospica Feclllty
<br />
<br />Grand Island, Nebraska
<br />
<br />o ER/Outpatient
<br />
<br />o Decodont's Horn.
<br />
<br />Saint Francis Medical Center
<br />
<br />OCO\
<br />
<br />o other (SpecifyL_
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island, 68803
<br />
<br />Be. COUNTY OF DEATH
<br />Hall
<br />
<br />,1gb. COUNTY
<br />Hall
<br />
<br />
<br />91. ZIP CODE
<br />68801
<br />
<br />9g.INSIDE CITY LIMITS
<br />111 YES 0 NO
<br />
<br />9d. STREET AND NUMBER
<br />2822 Brentwood Blvd.
<br />
<br />1 DB. MARITAL STATUS AT TIME OF DEATI; IXMarried 0 Navar Marriad 10b. NAME OF SPOUSE (First, Middle, Last, Suttix)It wilo, give melden name.
<br />
<br />o Married, but seporated Cl Widowed 0 Divorced 0 Unknown Mary Jo Hannon
<br />
<br />11. FATHER'S.NAME (First, Middle, Last, Suffix) I ;~. MOTHER'S-NAME (First, Middle, Malden surname)
<br />__.' John __R. ~::~dy ______~ ___ Mar~.~ J. Twomey
<br />
<br />13. EVER IN. .U. ..S. ARMED FORCES? Give dates .01 .ervice it YeS~'4a. ,INFORMANT'NAM. E 14b. RELATIONSHIP TO DECEDENT
<br />Y Ju~ ~6, ~943 Ma d . f
<br />(Yes, no, orunk.) as Mar 31, 1967 ry Jo Bra y W1 e
<br />
<br />15.METHOD'OFDISPOSITION sa:~...;'---;;ER-SI2-NATU~E-'~'-' /}. .' [1~b~LIC...E.NSENO:'- . jlBe.DATE (Mo.,Day,Yr.)
<br />DlBurial o Donollon li.~././(1.... 12./ ~ ~~_L!.?9~~. Oct 3, 2007
<br />
<br />OCramarion 0 Entombmerlt 1 16d. CEMETERY, CREMATORY OR 0 HER LOCATION CITY I TOWN STATE
<br />
<br />OOlher(Specify) Grand Island City Cemetery Grand Island NE
<br />
<br />__~,..___,_".""_------i.~-_.",,.__. -
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, $late)
<br />CUrran Funera~ Chapel 3005 South Locust
<br />
<br />PART I. Enter the cha.in...Q~--diseases, injuries. 01 compllcations.-that directly caused the death. DO NOT Qnter1ermlnal events such as cardiac arrest,
<br />
<br />r.epirotoly-o"..\~illUil>lllla\lQnwith"\i"llo",in!l-lhe.eliQI99Y. DO.NOT.ABBREVIATE. Enter only one causa on " lino. Add additional lines II necessary.
<br />
<br />IMMEO~AT SE
<br />..... l' ....-
<br />
<br />IMMEDIATE CAUSE (Final ~ . __ ~,a:~~...:..__..
<br />d1......"rcondltlonresulllng DUE TOCZO S A CONSEQUENCE OF.
<br />rnd..th) ~
<br />
<br />Sequen\ially IIs1condltrons, if (b) t/G.&iiJ )~ ell) j../f[A/.f
<br />
<br />any,l.adlngtothecauselloted -- DUE TO, OR AS A CONSEQUENCE OF m_
<br />on IIn...
<br />EnlBrUleUNDERLYING CAUSE
<br />(diee.s. or Injury thBl initiatod (c)
<br />thoevants ..suiting in d..th) --.'PUE TO, OR AS A CONSE~UENCE OF:
<br />lAST
<br />
<br />onSello aea~h
<br />
<br />onset to death
<br />
<br />
<br />.------1-__..
<br />I onset to death
<br />I
<br />I
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not rasulting in the undorlying C8Use given in PART I.
<br />
<br />1 g. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />a YES DI NO
<br />
<br />Cl Nol pregnant within past year
<br />Cl Pregnant at lime of death
<br />o Not pregnant, but pregnant within 42 days 01 death
<br />o Nol pragnant, but pregnen143 days to 1 year belore deeth
<br />o UnKnown if pregnant within the past year
<br />22.:DillOF INJURY (MO::'O~'\ 22b. TIME OF INJUR~
<br />
<br />-..--------.1.--....---
<br />22d. INJURY AT~ORK? 22e. DESCBIBE HOW )NJ),JRY OCC~F\RED
<br />
<br />o YES 0 NO
<br />_1.._.....__..
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT NO.
<br />
<br />o AccidentO Pending Invostigallon
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />o Passeng.r
<br />
<br />o Podestrian
<br />
<br />1:1 Other (Specity)
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />20. IF FEMALE:
<br />
<br />21a. MANNER OF DEATH
<br />DlNotural 0 Homicide
<br />
<br />o YES
<br />
<br />DlNO
<br />
<br />o Suicide LJ Could not be determined
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />22c, PLACE OF INJURY.At Mme, larm, street, factory, olliee building, construclion site, etc. (Specify)
<br />
<br />CrrYlTOWN
<br />
<br />SWE
<br />
<br />ZIP CODE
<br />
<br />23c. TIME OF DEATH
<br />5: 40 pm
<br />
<br />z > 1 24a, DATE 'SIGNED (M~., Day, Yr.)
<br />!'<lW
<br />~~ ---
<br />
<br />I ~ ~ 24C, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />D.a.4:~
<br />e.'" i: Z
<br />8 IE z 0 24e. On the basis of examinalion and/or investigation, in my opinion death occurred at
<br />.8 ~ ?l tho time. dote and placo and due to the cause(s) statod, (Signaturo and Title)"
<br />,2ll'<l
<br />815
<br />
<br />I Nb, TIME OF DEATH ---l
<br />
<br />_ ~""""'""""_ m_l
<br />m
<br />
<br />260. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />
<br />NO LJ PROBABLY 0 UNKNOWN .. 0 YES IX NO._ ..___.". Not Applicable if ~6e is No__9__ YES IX_~o
<br />27. NAME, TIT AN ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSiCIAN OR COUNTY ATTORNEY) (Type or 'Print)
<br />John A. Wagoner 800 Alpha St., Grand Island, NE 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />J.
<br />
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />OCT 5 2007
<br />
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