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<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAf~/5~RVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORr:YJJ;ffft~-'Jf!1rJt'=c_
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEfiFiON,.oWRIQH W"--
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~.(j~J-:4ii::;.~- )~:~~~~'~{
<br />DATE OF ISSUANCE ~K!/~J-...Ft.-,,"\,.--., 't,
<br />;"Aii~H.'iJbDPER \ ?~: ~:1
<br />APR 1 8 2005 ASSISTAN~STil,rEFie:qt.S:JJ!~~I:=
<br />LINCOLN, NEBRASKA HEALTH ANtJ.)jU~~~~~~~?
<br />
<br />-..
<br />
<br />200509718
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />CERTIFICATE OF DEATH
<br />
<br />
<br />
<br />1. DECEDENTS.NAME (Flrsl,
<br />
<br />Elmer
<br />
<br />Middlo,
<br />Boyd
<br />
<br />Lasl,
<br />Watson
<br />
<br />Suffix)
<br />
<br />2. SEX
<br />Male
<br />
<br />3. DATE OF DEATH (Mo.. Day, Yr.)
<br />April 4. 2005
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Wood River. Nebraska
<br />
<br />5a. AGE-Last Birthday
<br />(Yrs.1 84
<br />
<br />5b. UNDER: YEAR
<br />MOS. DAYS
<br />
<br />50. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />5. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />October 10. 1920
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />507-14-0137
<br />
<br />8a. PLACE OF DEATH
<br />l:lD.SPITAL:
<br />
<br />Xl Inpatienl
<br />
<br />OTHER: 0 Nursing Home/LTC 0 Hospice Facilily
<br />
<br />FACILITY-NAME (II nol Inslllullon, give streat and numbar)
<br />
<br />U ER/Oulpallant
<br />
<br />U Decedent's Home
<br />
<br />St. Francis Medical Center
<br />
<br />O!:O\
<br />
<br />o Olhar (Specify)
<br />
<br />80. CITY OR TOWN OF DEATH (Include Zip Coda)
<br />
<br />Nebraska
<br />
<br />68801
<br />J. 9b..COUNTY
<br />Hall
<br />
<br />8d. COUNTY OF DEATH
<br />
<br />Hall
<br />
<br />Grand Island
<br />ga. RESIDENCE-STATE
<br />
<br />1012 Lilley St.
<br />
<br />
<br />9t. ZIP CODE
<br />68883
<br />
<br />9g. INSIDE CITY LIMITS
<br />Kl YES 0 NO
<br />
<br />9d. STREET AND NUMBER
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH aI Married 0 Never Married 10b. NAME OF SPOUSE (First, MIddle, La~t, Suffix) If wife, give maiden name.
<br />
<br />o Married, but separated 0 Widowed 0 Dlvo,ced 0 Unknown June He 1 s e r
<br />
<br />11. FATHER'S-NAME (Fi'S!,
<br />Elmer
<br />
<br />Middle,
<br />L.
<br />
<br />Lasl, Suffix)
<br />Watson
<br />
<br />12. MOTHER'S-NAME (First,
<br />Alice
<br />
<br />Mlddla,
<br />A.
<br />
<br />Maldan Surnama)
<br />Cox
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dalas 01 servlca II yas. 14a.INFORMANT-NAME
<br />(Yes, no, or unk.) Yes: 9/22/42 1/9/46 June Wat son
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />15. METHOD OF DISPOSITION
<br />CIaUllal DDonallon
<br />
<br />16.. EMBALMER-SIGNATURE
<br />
<br />l{1u~~:
<br />
<br />
<br />16b. LICENSE NO. ~
<br />V" J3,;l!;-
<br />
<br />16c. DATE (Mo., Day, Yr. )
<br />April 8, 2005
<br />
<br />o Cremation 0 Entombment 16d. CEMETERY, CREMA
<br />
<br />CITY / TOWN
<br />
<br />STATE
<br />
<br />o Removal OOlhor(Spoolly) Wood River Cemetry,
<br />
<br />Wood River.
<br />
<br />Nebraska
<br />
<br />PART I. Enter the chain of eventsudiseasBs, injuries, or complications--that direclly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />raspl,alory arresl, or vantricular Ilbrlllallon wllhoul showing the etiology. DO NOT ABBREVIATE. Enle, only ona, causa on a line. Add additional lines II nacassa,y.
<br />IMMEDIATE CAUSE
<br />
<br />
<br />17a. c' 'NERAL HOME NAME AND MAILING ADDRESS (SI,eal, City o,Town, Slato)
<br />0,\ Brien-Strattman....ApfelFuneral Home .4115
<br />," It' I 'I' .
<br />
<br />(al
<br />
<br />,.f O,{l ; n- ,h ''1
<br />
<br />__._.._.___I"L___.._
<br />
<br />(j,t(}/1 c-41!-;(
<br />
<br />Ftr I/en{
<br />
<br />onset to death
<br />
<br />IMMEDIATo CAUSE (Final
<br />dlseas~ or condition resulting
<br />In dea'h)
<br />
<br />mu ~ll
<br />
<br />Saquenllally Its, <ondlllons, If
<br />any, leading to the t:ause listed
<br />on 1100..
<br />Enle' Ihe UNDERLYING CAUSE
<br />(disease or Injury that Initiated
<br />'he evenl. re.ultlng In death)
<br />LIST
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF: ,
<br />C i, (',pille
<br />
<br />onsallo daalh
<br />
<br />(bl
<br />
<br />/ s:: . f'",r:r
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsello dealh
<br />
<br />(e)
<br />
<br />-
<br />
<br />_.
<br />
<br />--~.'-
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on,et 10 dealh
<br />
<br />(dl
<br />
<br />o AccldantO Pandlnglnvasllgallon
<br />
<br />~-19" WAS MEDICAL EXAMINER--
<br />OR CORONER CONTACTED?
<br />
<br />o YES ~O
<br />..-....-. -.-.. --.--
<br />21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />o passangar
<br />
<br />U YES
<br />
<br />IBiiO
<br />
<br />PART It. OTHER SIGNIFICANT CONDITIONS-conditions conlrlbuting 10 Ihe death bul nol resulling In Ihe underlying cause glvan In PART I.
<br />
<br />O'4k/v
<br />
<br />o Not pregnant within past year
<br />o Pregnanl alllme 01 doalh
<br />U Not pregnant, but pregnant within 42 days of death
<br />U Nol pragnanl, blll pregnanl43 days 10 1 year betore death
<br />q .linknown II pregnenl within the pa't year
<br />
<br />21a.MA~ER OF DEATH
<br />l!I"Natural 0 Homicide
<br />
<br />o Pec:estrlan
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />o Suicide 0 could nol be del ermined
<br />
<br />o Olhar (Spacily)
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJUR: -J22C' PLACE O:_INJUHYOAI home, far~, slraat, laclory, ofllee bU'ldlng,c;nsirucllo~ ..t.e~e~.(SpecifY)
<br />
<br />
<br />"e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />DYES 0 NO
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYIfOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />"I' i/ tJS'
<br />
<br />24a. DATE SIGNED (Mo., Day. Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />>-~ ~
<br />JJ~a::
<br />llUlO
<br />,,~~
<br />-all-C(~
<br />E"'>-Z
<br />8ffi!zO
<br />.8Z">
<br />,!lli8
<br />O~
<br />() 0
<br />
<br />m
<br />
<br />24c. PRONOc:,CED DEAD (Mo., Day, yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the tasis of examinatIon and/or lnvestlgallon, In my opinion death occurred at
<br />Ihe lime, dale and place and duelo Ihe cau.e(s) slaled.(Signalura and TllIa) .,
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />DYES 0 NO IB'PROBABLY U UNKNOWN 0 YES C!t'NO
<br />
<br />2'/ N~~;;LE s:~~.i~s 6F~~ii~~ER(PHY{1116 CW~NEFS;iYdll'~~R ~4(rO :TTORGiJ~~t Ii~land ,
<br />
<br />25b. WAS CONSENT GRANTED?
<br />
<br />Nol Applicable II 25a Is NO_r.:.l. .~ES 0 NO
<br />
<br />NE 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />~.
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.1
<br />
<br />APR 1 4 2005
<br />
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