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<br />
<br />7\
<br />
<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., JV ~,J~~~ _ ~
<br />NOV 1 6 2007 ,..,...-.~ItT-4.N~;S:Gq6iFft, -
<br />2008029 OJ AS$Isf.A(ft!..1;-"'ATE REt!D$/Jiit[i;;,,:'
<br />LINCOLN, NEBRASKA HEAl- 7iJf IfND HUMAR SERVir(1fs .~.
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER'llclitF!N~t~D $}J T ~ :~
<br />CERTIFICATE OF DEATH~ ..;. : ~ J1 . J~:.. : - .I
<br />
<br />1. DECEDENT'S-NAME (First,
<br />Shirle Ann Buck
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />L..t,
<br />
<br />
<br />Middle.
<br />
<br />Sullil)
<br />
<br />sa. AGE-Lasl Birthday
<br />(Yra.)
<br />
<br />Palmer, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />72
<br />
<br />6a. PLACE OF DEATH
<br />
<br />506-40-1281
<br />
<br />H.QQfJJAl.:
<br />
<br />o Inpatient
<br />
<br />QlliEB: I!l Nursing HomelLTC 0 Hospice F.Cllity
<br />
<br />II:
<br />
<br />~
<br />II:
<br />is
<br />...
<br />~
<br />lI.I
<br />;z:
<br />~
<br />j
<br />'"
<br />~
<br />i
<br />'l5..
<br />E
<br />8
<br />
<br />8b. FACILITY-NAME (If not In.tilulion, giv~ .tre~1 .nd number)
<br />
<br />o Decedent.. Home
<br />
<br />o ER/Oulp.tient
<br />
<br />o !XlII 0 Olher(Speclly)
<br />Bd. COUNTY OF DEATH
<br />
<br />St. Francis Memorial Health Center LTC
<br />Be. CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />Grand Island 68803
<br />Oa. RESIDENCE-STATE
<br />
<br />
<br />Og.INSIDE CITY LIMITS
<br />(j YES Cl NO
<br />
<br />Ill. COUNTY
<br />
<br />Nebraska
<br />Yd. STREET AND NUMBER
<br />
<br />Hall
<br />
<br />01. ZIP CODE
<br />
<br />68801
<br />lOb. NAME OF SPOUSE (First. Middle, Last, SUfIIX) HWHe, give maldanneme.
<br />
<br />443 E. Hall St.
<br />10.. MARITAL STATUS AT TIME OF DEATH iii M.rrled 0 Nev.r M.rned
<br />
<br />o Marned, bul.eparated 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Kenneth Buck
<br />
<br />SuflIx)
<br />
<br />12. MOTHER'S.NAME (First,
<br />Bernice Burkman
<br />
<br />..
<br />III
<br />~
<br />
<br />11. FATHER'S-NAME (Fir.t,
<br />Paul Ewers
<br />13. EVER IN U.S. ARMED FORCES? Give date. of .ervlce lIye..
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />16c. DATE (MO.. D.y, Yr. )
<br />November 12, 2007
<br />STATE
<br />
<br />Middle,
<br />
<br />Leal,
<br />
<br />Middle,
<br />
<br />Mald.n Surn.me)
<br />
<br />
<br />lYe., no, or unk.1 No
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />IllI Bu~al 0 Donation
<br />
<br />
<br />CITY /TOWN
<br />
<br />o cl8maoon 0 Entombmenl
<br />
<br />o Removal Cl Oll1er(speclfy)
<br />
<br />Wesllawn Memorial Park
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Straat, City or Town, Stata)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />
<br />c
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEOtATECAUSE(Fllal
<br />d18ea.. orcOIldlUonrelUKlng
<br />l1dealh)
<br />
<br />
<br />16. PART I. Enl.r the ch.ln of event...dI......, InJu~e., or compllcaUon...th.t dlreclly c.u.ed the de.th. 00 NOT ent.r t.nnlnsl event. .uch.s c.rdI.c .rr..~
<br />re.plratory arrest. orvantrlcul.r nb~lIation without showing the aOology. 00 NOT ABBREVIATE. Enter only ona cause on a IIna. Add addlOonal nnesll necassary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />oosetlo death
<br />
<br />(a)
<br />
<br />on.at to daath
<br />
<br />8equenllflllr IlIlcondlUoo., n
<br />q, loading \0 th. ..u.. U.lad
<br />on 11111..
<br />EnIor... UNDERLYING CAUSE
<br />(dl.e_ or 11Jt-y lhall1lUalad
<br />the even" reeullng 11 deall)
<br />lJ6f'
<br />
<br />(b)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on.alto de.th
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />anselto de.lh
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS.CondlUona cont~buting to Iha daath bul nol resulllng In the undarlylng causa glvan.n PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />Cl YES NO
<br />
<br />0/1./ ,....v'T,..,v,J ...a~,~.
<br />
<br />/~...r./_
<br />
<br />II:
<br />I!I
<br />LL
<br />~
<br />lI.I
<br />l,)
<br />j
<br />~
<br />..
<br />~
<br />E
<br />8
<br />!
<br />~
<br />
<br />20, FEMALE:
<br />
<br />Nol pregnant within past yaar
<br />
<br />o pragn.nt.t Uma 0' d..1h
<br />
<br />o Nol pregn.nl. but pregn.nt wllhln 42 d.y. 0' d..1h
<br />
<br />o Nol pr.gnant, bul pregnant 43 day. to 1 yearb.lor. d.alh
<br />
<br />o Unknown it pr.gn.nl within the p..1 y..r
<br />
<br />21a,M EROFDEATH
<br />Natural 0 HomiCide
<br />
<br />21b.IFTAANSPORTATION INJURY
<br />o D~lIer/Oparator
<br />
<br />o pas_gar
<br />
<br />o P.dasl~.n
<br />
<br />o Olher (Speafy)
<br />
<br />21c. WAS AN AUTOPSY P~RMED?
<br />o YES ~O
<br />
<br />o AccidentO Panllng Inv..OgaUon
<br />o Sl.iclda IJ Could not ba dalannlned
<br />
<br />21 d, WERE AUTOPSY FI NDINGS AV AI LABLE TO
<br />COMPLETE CAUSE OF ~H?
<br />o YES ~O
<br />
<br />22.. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY.At homa, farm, street, ractory. olllce building, construction sUe, atc, (Spaclfy)
<br />m
<br />
<br />22d.INJUAY AT WORK?
<br />
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />DYES 0 NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT, NO.
<br />
<br />crrY/T(')\o\IN
<br />
<br />S11ITE
<br />
<br />ZIP CODE
<br />
<br />!'~
<br />i!:!
<br />1l~
<br />'iif~
<br />~ g-~
<br />.H
<br />,!!~
<br />
<br />23a. DATE OF DEATH (Mo., D.y, Yr.)
<br />
<br />November 6, 2007
<br />
<br />23b. DATE SIGNED (Mo.. Day, Yr.)
<br />November 9, 2007
<br />
<br />23d. To the best 01 rTtf
<br />and dua to
<br />
<br />24e. Olllha basiS 01 axal11naOon and/or Invesugauon, In rTtf opinion death ocCUrted at
<br />Iha ume, dale and place and due 10 lI1e caU5e(S) stated. (Slgn.tur. .nd TlUe ) T
<br />
<br />24a, DATE SIGNED (Mo" Day, Yr,)
<br />
<br />24D. TIME OF DEATH
<br />
<br />...~~
<br />.aoz
<br />ig!~
<br />lf~~
<br />E.'" >- <I:'
<br />llffi!ZO
<br />.z::J
<br />.a08
<br />,!!~
<br />1.115
<br />
<br />m
<br />
<br />
<br />23C. TIME OF DEATH
<br />10:30 pm
<br />
<br />24c. PRONOUNCED DEAD (MO.. Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />26a. HAS OAGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />o YES NO 0 PROBABLY 0 UNKNOWN 0 YES ~O
<br />27. NAME, TITLE AND ADDRESS OF CERTIAER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) ('tYPe or Pllnt)
<br />Jane McDonald, M.D., 800 Alpha St , Grand 1s1
<br />
<br />2Gb. WAS CONSENT GRANTED?
<br />
<br />Nol Appllcablalf 26a la NO IJ YES
<br />
<br />o
<br />
<br />28a, REGISTRAR'S SIGNATURE
<br />
<br />
<br />Nebraska 68803
<br />
<br />28b, DATE FILED BY REGISTRAR (1.10" Day, Yr.)
<br />
<br />NOV 1 3 2007
<br />
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