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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 />:::;::~~:::::~TORY FOR VITAL RECORDS. ...........M.. '. ....... ...........J;..........Af(..r...........~...'.;t........~.....\ . "..'
<br />OCT 1 8 2007 2 0 0 8 0 4 4 9 9 ''!S€'Zl.(fAf/!R;~elQ~'' "'l!fJ', .
<br />LINCOLN NEBRASKA ~:d." .'R.'. ...~~~=.irt... ..................1,;~J....{(..:."l.............
<br />, '. ...... . ,n" . .' ....... ...,'/;.,.....,.
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SE. RV.IC.E$...E.I~.' Ii. .E...... .~. .~.. P '.. ~.... >.ii.,,":;'
<br />CERTIFICATE OF DEATH'" =:- ~"~ j,'!:If ' 'fF"
<br />~,ia;:~~'Ol=!iiM\i i~~Il9y,'(r.}
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<br />
<br />"~}... ~Ii1it€P~lR1'l!rtMQ"Day, Yr;)
<br />IN.~" ~. ',:.-' J'
<br />
<br />1. DECEDENT'S.NAME (First,
<br />John William Kimberly
<br />4. CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />
<br />
<br />November 10,1925
<br />
<br />Mlddl.,
<br />
<br />Last,
<br />
<br />Sulfix)
<br />
<br />5a. AGE-La.1 Birthday
<br />
<br />(Yrs.)
<br />
<br />a:
<br />g
<br />u
<br />~
<br />Q
<br />
<br />Risin Cit, Nebraska
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />507-20-9290
<br />Bb. FACILITY-NAME (If not In.lIlullon, glv~ slr~~t and number)
<br />
<br />~ ERlOulpah~nl
<br />
<br />o Decedenfs Home
<br />
<br />81
<br />
<br />Ba. PLACE OF DEATH
<br />~:
<br />
<br />o InpaUenl
<br />
<br />QWW: 0 NUl1lng HomelLTC 0 HOSpice Facility
<br />
<br />O~
<br />
<br />o Olher(Speclfy)
<br />Bd. COUNTY OF DEATH
<br />
<br />Saint Francis Medical Center
<br />Bc, CITY OR TOWN OF DEATH (Include Zip Codo)
<br />
<br />Grand Island 68803
<br />9S. RESIDENCE.STATE
<br />
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<br />ill
<br />
<br />(lb. COUNTY
<br />
<br />
<br />9g.INSIDE CITY LIMITS
<br />
<br />iii YES 0 NO
<br />
<br />Nebraska
<br />ad. STREET AND NUMBER
<br />
<br />Hall
<br />
<br />9UIP CODE
<br />
<br />2745 O'f1anni an
<br />lOa, MARITAL STATUS ATTIME OF DEATH iii Married 0 Nover Married
<br />
<br />68803
<br />lOb. NAME OF SPOUSE (Flral, MlddlO, Last, Sumx) If wife, glvo malaon name.
<br />
<br />o Marn.d. butsoparatea 0 Wlaowod 0 Dlvorcod 0 Unknown
<br />
<br />
<br />Mald.n Surnam.)
<br />
<br />Mlddlo,
<br />
<br />Last,
<br />
<br />(First,
<br />
<br />Middle,
<br />
<br />11. FATHER'S.NAME (FlrSI,
<br />
<br />$. Homer Kimberl
<br />13, EVER IN U.S. ARMED FORCES? Give dales of sOlYlc.1f yos. 14a.INFORMANT-NAME
<br />(Yes. no. orunk.) Yes 8/30/43-3/28 46 Bonnie Kimberly
<br />15. METHOD OF DISPOSITION 16a. EMBALMER.SIGNATURE
<br />o Bu~al 0 Don.Uon Not Embalmed
<br />I2lI CremaUon 0 Enlombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />o Removal 0 Oth.r (Sp.clfy)
<br />
<br />1Gb. UCENSE NO.
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Wife
<br />
<br />16c, DATE (Mo.. Day, Yr, )
<br />
<br />October 2, 2007
<br />
<br />STATE
<br />
<br />CITY I TOWN
<br />
<br />Central Nebraska Cremation Service
<br />17a. FUNEAALHOME NAME AND MAILING ADDRESS (Street. Clly or Town, Slate)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />Be instructions In
<br />
<br />Nebraska
<br />17b. Zip Codo
<br />68801
<br />
<br />Gibbon
<br />
<br />
<br />
<br />APPROXIMATE INTERVf\L
<br />
<br />18. PART I. Entor lh. cnsln or events--dlseases, InJu~.s, or compllc:ations--th.1 dlr.clly c.used the d.ath. DO NOT enl.r terminal evenl. .uch as cardiac arr.s~
<br />resplralory arresl, or vontrlcularlIMllation without showing Iho olology, DO NOT ABBREVIATE. Enlor only one c.us. on .lIno. Add addlllonalIln..If n.c....ry.
<br />IMMEDIATE CAUSE:
<br />
<br />on..llo death
<br />
<br />l""'EDlATE CAUSE (Fhal
<br />dll_ orcandllon "''''ftlng
<br />h d8elh)
<br />
<br />
<br />on..lto death
<br />
<br />
<br />8aquantJally Ital condlUont,1l
<br />lIlY, IMdIng 10 lh8 CIUM .n'tad
<br />an Ihn.
<br />Ent8r tit UNDERLYING CAUSE
<br />(dlH....orInJlrfth.,hlllaled (c)
<br />lhttvtllta"'tub1ghd....1 DUE TO, ORASA CONSEQUENCE OF:
<br />lAST
<br />
<br />onsollO d.alh
<br />
<br />ons.llc aoath
<br />
<br />(d)
<br />
<br />lB. PART It. OTHER SIGNIFICANT CONDITIONS-Conditions cont~buUng 10 th. death bul nol r..ulllng In tho underlying cause gIVen In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />XI YES 0 NO
<br />
<br />21c, WAS AN AUTOPSY PERFORMED?
<br />
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<br />
<br />21a. MANNER OF DEATH
<br />UNalural 0 HomiCIde
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />o Drlv.r/Operalor
<br />
<br />o Passenger
<br />
<br />o P.deslrlan
<br />
<br />o Othor(Speclfy)
<br />
<br />XlNO
<br />
<br />20. IF FEMALE;
<br />o Notpregnent wllhln past year
<br />o Prognantat Ume of d.eth
<br />o Not pregnant. bul pregnant wtthln 42 days 01 aoath
<br />o Nol pr.gnant, but pregnant 43 days to 1 y.ar bolore doath
<br />o Unknown It pregnanl wllhln the pasl year
<br />
<br />DYES
<br />
<br />o AccldenlO Pendng InvesUgallon
<br />o Sulcido 0 Could not be dotermlned
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPlETE' CAUSE OF DEATH?
<br />DYES IXI NO
<br />,ilriKliClOif,Olllw ~atiU<;lIon "It; etC. (SpteIIy)
<br />
<br />II
<br />$.
<br />
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />DYES 0 NO
<br />
<br />22.. DESCRIBE HOW INJURY OCCURRED
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />ZIP CODE
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />
<br />238. DATE OF DEATH (Mo.. DSY, Yr.)
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr,)
<br />October 2. 2007
<br />24c. PRONOUNCED DEAD (Mo" Day, Yr.)
<br />October 1. 2007
<br />
<br />24d, TIME PRONOUNCED DEAD
<br />0134 a m
<br />
<br />240. TIME OF DEATH
<br />0134
<br />
<br />1>~i
<br />1l"'~
<br />lfc~
<br />li't:~
<br />uwZ
<br />"Z::l
<br />"'08
<br />.2~o
<br />
<br />Hall Count Attorne
<br />
<br />am
<br />
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />23c. TIME OF DEATH
<br />
<br />m
<br />
<br />23d. To Ihe beSI or my knowloage, aealh occurred altho tim., dal. and placo
<br />and due to th. caus.(s) stalod. (Slgnatur. and TIUe).,.
<br />
<br />24., On th. basis 01 oxamnoUon ond/orlnvosUgallon, In my opinion death occurred 01
<br />the ume. a~,1 ana place aod due to the caun(s) slatod, (Slgnaturo and mo ) .,.
<br />
<br />
<br />".
<br />
<br />25. DID TOBACCO USE CONTRIBUTETOTHE DEATH?
<br />
<br />DYES 0 NO 0 PROBABLY ~ UNKNOWN 0 YES l$l NO Not Appllc.bl.II 26a Is NO 0 YES 0 NO
<br />27. NAME. TITLE AND ADDRESS OF CERTIAER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (~pe or Pnnt)
<br />Mark J Yo n Hall Count Attorne S. Locust Street Grand Island NE 68801
<br />
<br />2Ba. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />OCT f5 2001
<br />
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