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<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL TH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR, Vlr..AJ~~'
<br />
<br />DATE OF ISSUANCE ~ \>'.. ~~fJ~
<br />
<br />~~~e-i.. lJ6P,';;:..,';.;~. ~ ~
<br />
<br />U~~:N\~B~~~ 20080553 4 ;i!~~~~"~'
<br />
<br />STATE OF NEBRAS~. DEPARTMENT OF HEALTH AND HUr.{A,~~VI~, i' ",' I" ,6:
<br />
<br />1.DECEDENT'S-NAME (First Mlddl., La.l. Suffix) a.a .;r,
<br />... ',I -,.',' .'!to'.. :'"f::"
<br />Male (' , ' . , .
<br />Sa. AGE.L..I Blrlhday Sb. UNDER 1 YEAR Sc, UN~1l1
<br />
<br />Francis Patrick Berney
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />
<br />(Yrs.)
<br />
<br />MOS. DAYS
<br />
<br />Greeley, Nebraska
<br />7, SOCIAL SECURITY NUMBER
<br />
<br />77
<br />
<br />March 29,1931
<br />
<br />Sa. PLACE OF DEATH
<br />~ 00 Inpoll.nl
<br />o ER/Oulpoll.nl
<br />oOOA
<br />
<br />QIIW!;. 0 Nursing Homo/LTC
<br />o Docodenr. Home
<br />o Dlh.rj8poclfy)
<br />
<br />o Ho.plce Feclllly
<br />
<br />0::
<br />o
<br />I-
<br />lrl
<br />II!
<br />Q
<br />oJ
<br />ffi
<br />z
<br />:::l
<br />Il.
<br />
<br />508-30-8227
<br />
<br />8b. FACILITY-NAME (If not Institution, ghf' street and number)
<br />
<br />Saint Frands Medical Center
<br />
<br />Sd. COUNTY OF DEATH
<br />
<br />8c. CITY OR TOWN OF DEATH (Includo ZIp Cod.)
<br />
<br />Grand Island 68803
<br />
<br />ga. RESIDENCE-8TATE
<br />
<br />9b. COUNTY
<br />
<br />
<br />68803
<br />
<br />Hall
<br />
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />
<br />9f. liP CODE
<br />
<br />gg. INSIDE CITY LIMITS
<br />
<br />IKI y.o 0 No
<br />
<br />~
<br />"g
<br />.!
<br />'[;
<br />!
<br />
<br />-a
<br />8
<br />u
<br />ell
<br />lD
<br />o
<br />I-
<br />
<br />1823 W. 11th St.
<br />
<br />100. MARITAL STATUS AT TIME OF DEATH 00 MOITI.d 0 Never Married 10b. NAME OF SPOUSE (Flrsl. Middle. La.l, Sulllx)If wlf.. give m.ld.n nom..
<br />
<br />o Married, bul..porol.d 0 Wldow.d 0 Divorced 0 Unknown
<br />
<br />
<br />11. FATHER'S-NAME (Flrol, Mlddl., Lo.L Sulllx)
<br />
<br />Mlddl., M.lden Sumom.)
<br />
<br />Berne
<br />
<br />McKinzie
<br />
<br />William
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dal.. of o.rvlc.lf Ye.. 14a.INFORMANT-NAME
<br />
<br />Wife
<br />
<br />
<br />(Y.., No. orunk.) Ya 02/29/1952-02/17/1954
<br />
<br />15. METHOD OF DISPOSITION 1So. E'lIeALMER-SIGNATURE
<br />!!I8u",,' o Donotlon ,/ r' <' .,' f) .
<br />o Cnnnatlo" 0 El1tombm.nt '
<br />o Romovo' oOlnorj.po.lfy) EMETERY, CREMATORY OR OTHER LO
<br />
<br />Westlawn Memorial Park Cemetery
<br />
<br />170. FUNERAL HOME NAME AND MAILING ADDRESS (S....L City or Town, 510101
<br />All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />17b. lip Cod.
<br />68801
<br />
<br />lie. DATE (Mo., D.y, Yr.)
<br />
<br />June 6, 2008
<br />
<br />STATE
<br />
<br />
<br />CAUSE OF DEATH See Instructions and exam
<br />
<br />if. P,AflT I. Enter the eft.ln of ewmt! . dl''''8SU, InJurt.., or comPIIc:..IQn.- th.t dlfttc:lly CIU.ed th. d..th. DO NOT am.r tennIMI.v.nlllauch a. cardiae 1m.',
<br />....plr.lory erntllt, ot v.nltlc"I., "brlllallan without .nowlng tM etiology. DO NOT ABBM~mTe. Enter only ona CIUH on I line. Add liddltlonllIIn..If fM'......ry.
<br />
<br />APPROXIMATE INTERVAL
<br />I on.elto dull>
<br />I
<br />"'1'V' A ~
<br />
<br />IMMEDIATE-CAU'SE:
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl..... or condition ....uIUng I)
<br />In d.olh)
<br />
<br />:"-h//
<br />
<br />
<br />onset to death
<br />I
<br />
<br />I
<br />
<br />r'.....-
<br />
<br />DUE TO, OR A CONSEQUENCE OF:
<br />
<br />S.qu.nUolly 11.1 condlllon.. If b)
<br />.ny,'..dlng to the c8u..U.ted
<br />on Itne ..
<br />
<br />
<br />onset to d..th
<br />
<br />r'~
<br />
<br />~ <I'/r'./
<br />
<br />e'//......-:
<br />
<br />Enl..lI>. UNDERLYING CAUSE c)
<br />(dl..... or Injury 1I>011nllle..d
<br />In. .v.nl. re.ulllng In d.oln) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />
<br />d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS~ondlllone conlrlbullng 10 In. d.oln bul nOlrooulllng In In. underlying couo. glv.n In PART I.
<br />
<br />18. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED7
<br />
<br />o YES 'to
<br />
<br />a1c. WAS AN AUT~,' P Y PERFORMED?
<br />DYES ~NO
<br />
<br />a1d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />DYES oNO
<br />
<br />IJ::
<br />W
<br />ii:
<br />ffi
<br />u
<br />j
<br />
<br />"g
<br />i
<br />c.
<br />g
<br />u
<br />&!
<br />-fl-
<br />
<br />ao. IF FEMAlE:
<br />o Nol pr.gnonl wllnln peel year
<br />o Pregnonl 01 lime of d.olh
<br />o Nol pregnonl, bul pregn.nl wllhln 4a doy. of d..lh
<br />o NOI pregnenl, bul pregnonl 43 dey. 10 1 yoor bolore de.lh
<br />oUnknown If pregnanl wllnln In. p'.1 year
<br />
<br />~. MANNER OF DEATH
<br />;Xl Nolur.1 0 Homlcld.
<br />o Accld.nl 0 Pending Inve.llgollon
<br />o Sulcld. 0 Could nOl be d.lermln.d
<br />
<br />a1b.IF TRANSPORTATION INJURY
<br />o Drlv.r/Oporelor
<br />o P....ngor
<br />o Ped..lrlan
<br />o Oll>.r (Speclty)
<br />
<br />22d. INJURY AT WORK7
<br />o YES UNO
<br />
<br />
<br />STATE
<br />
<br />liP CODE
<br />
<br />22.. DATE OF INJURY (Mo., D.y, Yr.)
<br />
<br />22b. TIME OF INJURY aac. PLACE OF INJURY.AI hom., f.rm, .Irool, feclory. omco building, cDn'lrucllon .11., ole. (Specify)
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYrTOWN
<br />
<br />a3.. DATE OF DEATH (Mo.. D.y, Yr.)
<br />
<br />240. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />.J~
<br />... !,!~
<br />i~o
<br />ll:I:l=>-
<br />1:1.11.0( ...I
<br />8 ~~ ~
<br />'-'wz
<br />"Z::l
<br />"'00
<br />~~~
<br />uo
<br />
<br />~~
<br />"'u
<br />
<br />I~>-
<br />1:1.11....1
<br />h'~
<br />.ii:
<br />...e
<br />o:!
<br />....0(
<br />
<br />June 2
<br />
<br />2008
<br />
<br />m
<br />
<br />
<br />a3c. 11ME OF DEATH
<br />
<br />240. PRONOUNCED DEAD (Mo., Day, Yr.) Md. TIME PRONOUNCED DEAD
<br />
<br />11:08 A.m
<br />
<br />m
<br />
<br />24.. On the b..ls of examlnatton and/or Inv..flgatlon, In my opinion death occurred
<br />at th. time, dlte and plaee and due to the cau.e(s) .tated. (Signature and TIUe)
<br />
<br />a8b. WAS CONSeNT GRANTED7
<br />NOI Applicable If a8. I. NO 0 YES
<br />
<br />NO
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH7 a80. HAS ORGAN OR TISSU~ONATION BEEN CONSIDERED?
<br />o YES ~NO 0 PROBABLY 0 UNKNOWN 0 YES J2!l. NO
<br />
<br />a7. NAME, TITLE AND ADDReSS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ArrORNEY) (Typ. or Prlnl)
<br />Jane Ao McDonald, M.Do, 800 Alpha st., Grand Island,
<br />
<br />Nebraska 68803
<br />
<br />as.. REGISTRAR'S SIGNATURE
<br />
<br />
<br />JUN 11 2008
<br />
<br />a8b. DATE FILED BY REGISTRAR (MO.. Day, Yr.)
<br />
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<br />~
<br />
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