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<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH A~N Sfi.~VICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGIN!tj:''71.WptfD'lr:JMf~!'Wj!H
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATJS"f.lf?S.~~., ?t;...W81ff,
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~' .,',....~.V" ~;~..."!7 J;
<br />", ~~'~~.J
<br />DATE OF ISSUANCE . ," . --. () "
<br />MAY 1 4 2008 A.~TA ~$7~~=:
<br />200 8 0 615 3 H6A~.ANDHUA1~'(SERit!C~ ::
<br />'.;,;; '. 'lI:,.., . 1\'" c~l.i'
<br />1';~".<.:aFtf e:\~..',.* 'if'
<br />{,,:,:........':-:.'.,,\)\ .....,4--
<br />.',' t. l. '.1 ," '-,I'{ '.,;i \,\ ",....'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCEAIIlD s0f.eiflfb 2 5 0 0: 7
<br />CERTIFICATE OF DEATH' U 0
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />1, DECEDENT'S.NAME (First,
<br />June
<br />
<br />Middle,
<br />Jeannette
<br />
<br />last,
<br />Watson
<br />
<br />Suffix)
<br />
<br />2. SEX
<br />Female
<br />
<br />3. DATE OF DEATH (Mo., Day,Yr,)
<br />May 7. 2008
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Doniphan. Nebraska
<br />
<br />Sa. AGE. last Birthday Sb. UNDER 1 YEAR
<br />(Yrs.) 84 MOS. DAYS
<br />
<br />50. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo., Dey, Yr.)
<br />June 13. 1923
<br />
<br />7. SOCIAl SECURITY NUMBER
<br />506-20-4144
<br />
<br />8a. PlACE OF DEATH
<br />1:iQ.SflTAL; ~ Inpatient
<br />
<br />QIl:IEB: Q Nursing HomallTC Q Hospice Facility
<br />
<br />8b. FACllITY.NAME (If not institution, give street end number)
<br />
<br />St. Francis Medical Center
<br />
<br />Q ER/Outpetient
<br />
<br />Q D.c.d.nt'. Hom.
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Cod.)
<br />Grand Island
<br />
<br />68803
<br />
<br />D [Xli\ D Other (Sp.clfy)
<br />
<br />6d. COUNTY OF DEATH
<br />Hall
<br />
<br />10e, MARITAL STATUS ATTIME OF DEATH Q[Married D Never Marri.d lOb. NAME OF SPOUSE (Fir.t, Middle, Last, Suffix) If wif., glv. mald.n name,
<br />
<br />
<br />9f. ZIP CODE
<br />68801
<br />
<br />9g.INSIDE CITY LIMITS
<br />Xl YES D NO
<br />
<br />9a, RESIDENCE.STATE 9b. COUNTY
<br />Nebraska Hall
<br />
<br />9d, STREET AND NUMBER
<br />404 Woodland Drive
<br />
<br />DMsrrled,butseparated DWidow.d DDlvorced QUnknown Marvin D. Watson
<br />
<br />11. FATHER'S.NAME (First,
<br />Earl
<br />
<br />Middle,
<br />
<br />Last,
<br />Shehein
<br />
<br />Suffix)
<br />
<br />12, MOTHER'S-NAME (First,
<br />Mary
<br />
<br />Middle,
<br />Beryl
<br />
<br />Maiden Surname)
<br />Jackson
<br />
<br />13. EVER IN U.S. ARMED FORCES? Giv. dete. of ..rvlce If y... 14a.INFORMANT-NAME
<br />(YeS,no,orunk.) No Marvin D. Watson
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />
<br />D Cr.metion D Entombment
<br />
<br />
<br />16b. LICENSE NO.
<br />13{)8
<br />
<br />16c. DATE (Mo.. Day, Yr, )
<br />May 12. 2008
<br />
<br />15. METHOD OF DISPOSITION
<br />iJlBurla' D Donetion
<br />
<br />CITY / TOWN
<br />
<br />STATE
<br />
<br />D Removal D Oth.r (Sp.cify)
<br />
<br />Grand Island Cemetery
<br />
<br />Grand Island. NE.
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Str..t, City orTown, Stet.)
<br />A fel Funeral Home 1123 West Second.
<br />
<br />r..plretory arrest, or v.ntrlculer fibrillation withoul showing the .tlology. DO NOT ABBREVIATE. Ent.r only on. c.use on . line, Add additional lines if neoessary.
<br />IMMEDIATE CAUSE:
<br />
<br />(a) .5c:' ps'
<br />DUE TO, OR AS A 1NSEQUENCE OF:
<br />
<br />Sequentially lilt condUlona, II
<br />any,lesdlng \0 the cau.. fllIIad
<br />on linea.
<br />Enter the UNDERLYING CAUSE
<br />(dluaae or InJUry thallnltllllad
<br />the events reaultlng In deslh)
<br />LASr
<br />
<br />(b)
<br />
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />ons.t to d.alh
<br />
<br />(d)
<br />
<br />16. PART II, OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the deeth but nol resulting in Ih. und.rlylng ceu.. glv.n In PART I.
<br />
<br />D Acold.ntD P.nding Inv..tlgatlon
<br />D Suicid. D Could not be determined
<br />
<br />21b.IF TRANSPORTATION INJURY
<br />D Drlv.r/Op.rator
<br />
<br />D P....ng.r
<br />
<br />D Pedastrian
<br />
<br />D Other (Sp.clfy)
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />DYES fK NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />JiI Nol pr.gnant within past yeer
<br />D Pregnant at time of d.ath
<br />D Not pr.gnant, but pregnant within 42 days of de.th
<br />D Not pr.gnent, but pregnent43 day' 10 1 year b.fore d.ath
<br />D Unknown if pr.gnant within th. p..t yea,
<br />
<br />DYES
<br />
<br />~NO
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAIlABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />DYES Q NO
<br />
<br />
<br />22a. DATE OF INJURY (Mo" Day, Yr,)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY.At home, larm, street, factory, offiC. building, construction sll., .Ic, (Specify)
<br />m
<br />
<br />22d, INJURY AT WORK?
<br />
<br />22f. LOCATION OF INJURY. STREET & NUMBER, APT. NO,
<br />
<br />CrTYlTOWN
<br />
<br />STPJE
<br />
<br />ZIP CODE
<br />
<br />23.. DATE OF DEATH (Mo" Day, Yr.)
<br />MAL7 2008
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />am
<br />
<br />:1'>-
<br />~:!51JJ
<br />II!~
<br />..ffi~
<br />1li5"
<br />,2f!i8
<br />..., 15
<br />
<br />m
<br />
<br />230. TIME OF DEATH
<br />6:12
<br />
<br />24c. PRONOUNCED DEAD (Mo., Dey, Yr,) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24.. On the ba.l. of .xamln.tlon and/or Inve.tigetlon, in my opinion d.eth occurr.d el
<br />the time, data and placa and due to the caus.(s) etat.d. (Slgnalur. end Title) .,.
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSiDERED?
<br />
<br />DYES )it NO D PROBABLY D UNKNOWN YES. D NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSiCIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Thomas Werner M.D. 2444 West Faidley Ave.. Grand
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />Not Applicabla if 26a is NO DYES;e NO
<br />
<br />Island. NE.
<br />
<br />68803
<br />
<br />2ge, REGISTRAR'S SIGNATURE
<br />
<br />
<br />26b, DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />MAY 1 J 2008
<br />
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