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<br />STATE OF NEBRASKA
<br />
<br />Q"
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<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL TH;AtviY-fiitiJMACJ. ,SER VICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB~"'1~:8..~AR1i"16Nt o.F HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY ~C?R'I{5~~~.~[!!P~D~, ':y:,:",
<br />
<br />DATE OF ISSUANCE ~A.~,
<br />
<br />JUl 3 1 200S 2008068 83 '~~~~i;4 ~O!E:~St~RJ
<br />D~A~T~Nt6t~ H~~,
<br />HU/'tUffo! 5f.RVICES . ,: _"7-1 pi
<br />.~ , II-'Y--' ~= ....
<br />'I ~''',!~'.'.~8R;l.S\''''.~~'~~"i4.:
<br />~' ", 's.~.... ........ . . . .. " .'\ ~ \ 4:JI
<br />'" '~, '1'-, I. "..:' U t \' ...\ , .~.'>". _..t..-.:i
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINA~\l J.No.SUl?PO ~-
<br />CERTIFICATE OF DEATH '. , "
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />
<br />1. DECEDENT'S.NAME (First,
<br />Leota
<br />
<br />Middle,
<br />Ruth
<br />
<br />
<br />Last.
<br />McClure
<br />
<br />Suffl.)
<br />
<br />2,SEX
<br />Female
<br />
<br />3, DATE OF DEATH (1.10" Day, Yr.)
<br />July 19. 2008
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Lincoln. Kansas
<br />
<br />Sa. AGE.Last Birthday 5b, UNDER 1 YEAR
<br />(Yrs,) MOS, DAYS
<br />83
<br />
<br />5c, UNDER 1 DAY
<br />HOURB MINS,
<br />
<br />6, DATE OF BIRTH (1.10" Day, Yr,)
<br />
<br />eptember 28. 1924
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />513-16-1628
<br />
<br />6a, PLACE OF DEATH
<br />
<br />J:t.Q.S.fJIAJ.:
<br />
<br />~ Inp.tlenl
<br />
<br />~ CJ Nur.ing Home/LTC CJ Hosplc. Facility
<br />
<br />FACILlTY.NAME (II not instilution, glv. .tr..t .nd numb.r)
<br />
<br />CJ ER/Outpatl.nt
<br />
<br />CJ D.c.d.nt'. Hom.
<br />
<br />St. Francis Medical Center
<br />
<br />0[01.
<br />
<br />o Oth.r (5pecify)
<br />
<br />6c. CITY OR TOWN OF DEATH (Includ. Zip Cod.)
<br />Grand Island 68803
<br />
<br />6d, COUNTY OF DEATH
<br />Hall
<br />
<br />9., REStDENCE-STATE
<br />Nebraska
<br />9d, STREET AND NUMBER
<br />2203 West 1st St.
<br />
<br />9b. COUNTY
<br />Hall
<br />
<br />
<br />91. ZIP CODE
<br />68803
<br />
<br />9g, INSIDE CITY LIMITS
<br />
<br />Xl YES CJ NO
<br />
<br />10e, MARITAL STATUS AT TIME OF DEATH Ill[ Marrl.d 0 N.v.r M.rrleo lOb. NAME OF SPOUSE (First, Middl., Last, Sulll.) If wit., give maiden nam..
<br />
<br />CJ Marri.d, but s.p.r.ted 0 Widow.d CJ Divorced 0 Unknown
<br />
<br />L.,.
<br />
<br />Charles G. McClure
<br />
<br />11, FATHER'S-NAME (Fir.t,
<br />John
<br />
<br />Middle,
<br />A.
<br />
<br />Last,
<br />Pankau
<br />
<br />Sulfi.)
<br />
<br />12, MOTHER'S.NAME (Fir.t.
<br />Irene
<br />
<br />Middle,
<br />Ruth
<br />
<br />Maiden Surname)
<br />Markham
<br />
<br />13. EVER IN U,S, ARMED FORCES? Giv. dat.. of ..rvic.1f yes, 14a.INfORMANT.NAME
<br />(Y.S,nO,orunk,) No Charles G. McClure
<br />15, METHOD OF DISPOSITION
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Husband
<br />
<br />o Burial
<br />
<br />o Don.tlon
<br />
<br />
<br />
<br />16c, DATE (Mo" Day, Yr,)
<br />July 22. 2008
<br />
<br />iI Crem.tlon CJ Entombm.nl
<br />o R.moval 0 Olher (Specify)
<br />
<br />CITY I TOWN
<br />
<br />STATE
<br />
<br />Central Nebraska Cremation Service
<br />
<br />17., FUNERAL HOME NAME AND MAILING ADDRESS (Slr.el, Clly or Town, Stat.)
<br />
<br />PART I, Ent.r the ch.in ol.v.ntsndiseas.s, injuries, or compllcalionsnlhat directly ceused Ihe d.ath, DO NOT .nt.r terminal.vents such as cardl.c .rrest,
<br />respir.tory .rr.st, or v.ntrlcular tibrill.llon wilMul showing Ih. .tlology, DO NOT ABBREVIATE, Ent.r only one caus. on a i1n., Add addlllonelllnes il n.c.ssary,
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />dlse.. or condition resulting
<br />In death)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />(a) LCl.v1&.,j&\ t:tlb'\LttlilSoo 5eps,.,'~
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />(b) I.n.fMUf10SUrrw.ss{~ &;. 5krr"'~
<br />
<br />onsel to d.alh
<br />
<br />S.qu.ntlaily lI.t condltian.,II
<br />.ny,lo.dlngtoth.cauaell.1ed DUE TO, OR AS A CONSEQUENCE OF:
<br />on IIn..,
<br />Entorth.UNDERLYINGCAUSE '7) } j} (
<br />(dt.....ortnjuryth.t1nlll.l.d (c) rO "1 )A.4av'~~
<br />th.ovenl.re.ultlng Indoath) DUETO, OR AS A CONSEOUENCE OF:
<br />I.ASl'
<br />
<br />,...keu. r1A~'ca-
<br />
<br />I .3 ')..U?e~~
<br />
<br />, onset to death
<br />I
<br />
<br />,~~---
<br />
<br />I onsel to de.th
<br />I .
<br />
<br />~._~
<br />
<br />I onset to d.ath
<br />I
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS,Condltlon. contributing to the dealh but nol resulting in the und.rlylng c.use gll/(n in PART I. ""
<br />Ro I/I.&t.f J4.1SUil11'C-It"e--t ~ J PnetA~o~a.., L,- L'2- u ts,)c.t' S
<br />
<br />o Accio.nlO P.nding Inv.stlgatlon
<br />CJ Suicide 0 Could not b. d.t.rmlned
<br />
<br />21 b,lFTRANSPORTATION INJURY
<br />CJ Drlver/Operator
<br />
<br />CJ p..seng.r
<br />
<br />o Pedestrian
<br />
<br />o Other (Specify)
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />o YES ~NO
<br />21c, WAS AN AUTOPSY PERFORMED?
<br />
<br />20, IF FEMALE;
<br />JlQ Not pregnant within past y..r
<br />CJ pr.gn.nt al time 01 d.alh
<br />CJ Not pr.gnent, but pr.gn.nl within 42 d.ys of death
<br />o Not pregnant, bul pr.gnant43 d.ys to 1 year betor. d.ath
<br />o Unknown If pr.gn.nt within the pasl y.er
<br />
<br />21., MANNER OF DEATH
<br />:I(l'Natural CJ Homicide
<br />
<br />CJ YES ~NO
<br />
<br />o YES 0 NO
<br />
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES ill NO
<br />
<br />22a, DATE OF INJURY (Mo" Day, Yr,)
<br />
<br />22b, TIME OF INJURY 22c, PLACE OF INJURY-At home,larm, streel, factory, offlc. building, construction sil., .tc, (Sp.clfy)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO,
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />24., DATE SIGNED (1.10" Day, Yr,)
<br />
<br />24b, TIME OF DEATH
<br />
<br />m
<br />
<br />z>
<br />""Sill
<br />.a~~
<br />h5~
<br />H~~
<br />llz:;)
<br />~~~
<br />
<br />m
<br />
<br />24c, PRONOUNCED DEAD (1.10" D.y, Yr,) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To t . b..t of my knowl.dge, death occurr.d at the tlm., date ano plac.
<br />ano du.lo the cause(s) stated, (Signalur. and Titl.) ...
<br />
<br />/If;i;;.
<br />
<br />24., On the basi. ot ...mln.llon and/or inv.sligatlon, in my opinion death occurr.d at
<br />the tim., date and plac. .nd due to th. caus.(s) stal.d, (Slgnatur. .nd Title) 'f
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />CJ YES :le.NO 0 PROBABLY CJ UNKNOWN CJ YES NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. or Print)
<br />Richard Fruehling M.D. 2116 W. Faidley Ave.. Grand
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />Not Applicabl. it 26. I. NO 0 YES
<br />
<br />NO
<br />
<br />Island. NE
<br />
<br />68803
<br />
<br />2Ba. REGISTRAR'S SIGNATURE
<br />
<br />
<br />2Bb, DATE FILED BY REGISTRAR (Mo" Day, Yr,)
<br />
<br />JUL 2 9 2008
<br />
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