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<br />... ~ <br /> <br />Q... <br />\\ <br /> <br />STATE OF NEBRASKA ., <br /> <br />WHEN THIS COpy CARRIES THE RAISED SEAL QP THE NEBRASKA HEALTH AND IwMANSER.VlCES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRl!E COpy OF THE ORIGINAL REC-"'--" Fli1iwITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS1ES:SY;TiDfI.---ft1tIICH'IS <br /> <br />:~:~::~::ORY FOR Y1TAL RECOROS'~}jj~~~ <br />MAR 1 9 2007 20080772 t "rffr~~~;tt@;SR <br />A~S1$1ARf SWii-REGisiFii.R <br />H~~~1N~.,~~r:J!}g~rS <br /> <br />"'7":....:.': _ _ ~ .,. ._n_ <br />,~ ".. <br />STATE OF NEBRAsKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE~llJD SJ;:iFPORT <br />. _~RJIFICATE OF DEATH 'c"~-~'~.-c-:';-' 07 2 ~ 6- <br />1. DECEDENT'S.NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEA~H (Mo" Day, Yr.) <br /> <br />LINCOLN, NEBRASKA <br /> <br /> <br />Ainsworth. Nebraska <br /> <br />r. <br />5a. AGE.Last Birthday 5b. UNDER 1 YEAR <br />(Yrs.) MOS. DAYS <br />79 <br /> <br />..~ <br /> <br /> <br />8.,--.2QO~- <br />6. DATE OF BIRTH (Mo., Day, Yr.) <br /> <br />Richar:d. Jo.s.eI2h-_. .):Jb <br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH <br /> <br />5c. UNDER 1 DAY <br />HOURS MINS. <br /> <br />August 30. 1927 <br /> <br />7. SOCIAL SECURITY NUMBER <br /> <br />8a. PLACE OF DEATH <br />1::lillil'lIAl.: <br /> <br />o Inpatient <br /> <br />QlliEB: <br /> <br />~ursing Home/LTC 0 Hospice Facility <br /> <br />.~ <br /> <br />507-26-3258 <br />fl"~""uw'''"' '''"'' '"''''"''"". "";,,,,, ,"I ",;;", <br /> <br /> <br /> <br />1~~;;:'U";;1arrl' Nebras~~803 <br /> <br />,y:t-,t __----.!!e~raska_. Hall <br />"I' Z 9d STREET AND NUMBER <br />~(, ;j' 508 W. Medina <br />fj;1 __,'''0_ <br />\; ~~ 10.. MARITAL STATUS ATTIME OF DEATH I2IMarrled 0 Nevor Marrlod <br /> <br />,'4 '\ 0 Marrlod, but.oparaled 0 Widowed 0 Dlvorcod 0 Unknown <br />T" 1,/ <br />" <br />I _ ""------~.~ <br />Jit'; 11. FAT'HER'S.NAME (First, <br />,io' .~ Richard <br /> <br />o ER/outpallont <br /> <br />o D.codent's Hom. <br /> <br />Grand Island Veterans Home <br />2300 W. Ca ~ tal Avel1Ue <br />Be. CITY OR TOWN OF DEATH (Include Zip Code) <br /> <br />0[0\ <br /> <br />o Other (Speeily)_ <br /> <br />ad. COUNTY OF DEATH <br /> <br /> <br />Hall County <br /> <br />91. ZIP CODE <br />68824 <br /> <br />9g. INSIDE CITY LIMITS <br />~ YES 0 NO <br /> <br />lOb. NAME OF SPOUSE (First, Middle, Last, Suffix) II wile, givo maiden nome. <br /> <br />Alta Jean Brown <br /> <br /> <br />Middle, <br />Joseph <br /> <br />La.t, Suffix) <br />Mohanna Sr. <br /> <br />12. MOTHER'S.NAME (Flr.t, <br />Wilda <br /> <br />Middle, <br />Mae <br /> <br />M.lden Surname) <br />Nelson <br /> <br />13. EVER IN U.S. ARMED FORCES? Give detes ol.ervleoll yes. 14a.INFORMANT.NAME <br />(Yes:':h~.s.nk.) 6/27/1945 8/23/1946 AHa Jean Mohanna <br /> <br />14b. RELATIONSHIP TO DECEDENT <br />Wife <br /> <br />CITY /TOWN <br /> <br />16e.. DATE (Mo., Day, Yr.) <br /> <br />March 11 ,.2007 <br />STATE <br /> <br />~Cremallon 0 Entombmant <br />o Removal 0 Olher (Speclly) <br /> <br />.1.6a::~LMER'SIGNdE~~ . ......_.... <br />16d. C~REMATORY OR ~ER LOCATION <br /> <br />16b. LICENSE NO. <br /> <br />13~8 <br /> <br />15. METHOO OF DISPOSITION <br />o Burial ODonallon <br /> <br />Westlawn Memorial Park Crematory <br /> <br />Grand Island. NE <br /> <br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Straat, Clly or Town, State) <br />Apfel Funeral Home, 1123 West Second <br /> <br />PART 1. Enter the !!.b..ai~--dlseases, injurieS, or compllcations--thal directly caused 'he death. DO NOT enter termInal events such as cardiac arrest, <br />re.piratory arresl, or v.ntrieulor librill.tion without showing the etiology. DO NOT ABBREVIATE. Enter only one cau.. on .llne. Add additionallln.. if naceaaary. <br />IMMEDIATE CAUSE: <br /> <br />ons.llo doath <br /> <br />IMMEDIATE CAUSE (Final <br />disease or condition resulting <br />In d.ath). <br /> <br />S.qu.nttally liot condltton., If (b) <br />any, loading to the e.u.olioted -DUE TO, OR AS A CONSEQUENCE OF: <br />on IIn8 a. <br />Entor tha UNDERLYING CAUSE <br />(dl..... or Injury thet Inltt.t.d (c) <br />the .vent. r..ultlng In death) DUE TO, CiR AS A CONSEQi.lliN~ <br />lASl' <br /> <br />(.) <br /> <br />Pneunonia <br /> <br />:<10 day~. <br /> <br />I onset to death <br /> <br />DUE TO, OR AS A CONSEQUENCE OF: <br /> <br />20. IF FEMALE: <br /> <br />21a. MANNER OF DEATH <br />::8tJatural 0 Homicide <br /> <br />o AccidantU P.nding Inveatlgation <br /> <br />I <br />I <br />I <br />I onset to d.alh <br />I <br />I <br /> <br />~__ .L--.._ .___._ <br />I onset 10 death <br />I <br />I <br />. "..,.1.__.,---" <br />~19' WAS MEDICAL EXAMINER <br /> <br />OR CORONER CONTACTED? <br /> <br />o YES .~NO <br />.,- ,."'-" <br />21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? <br />o Drlver/Oporator <br /> <br />(d) <br /> <br />18. PART II. OTHER SIGNIFICANT CONDITlONS.Conditions contributing 10 the d.ath but not resulting In tho underlying cause given in PART I. <br /> <br />parkinson's Disease <br /> <br />o Suicide 0 Could not be determined <br /> <br />o Passenger <br />o Padestrian <br />o Olh.r (SpoGlly) <br /> <br />DYES <br /> <br />!i\:NO <br /> <br />o Not pregnant within past year <br />o Pregnant ,t tim, 01 death <br />o NOI pregnant, but pregnanl within 42 days 01 death <br />o Not pregnant, but pregnant 43 days to 1 year betoro death <br />o Unknown If pregnanl within the pa.t year <br /> <br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO <br />COMPLETE CAUSE OF DEATH? <br />DYES 0 NO <br /> <br /> <br />22a. DATE OF INJURY (Mo., Day, Yr.) <br /> <br />22b. TIME OF INJURY 220. PLACE OF INJURY.At hom., form, street, f.ctory, offlc. building, con.truction site, ele. (Specify) <br />m <br /> <br />m:lN"JLIRY AT WORK? - JDiiSCRIBE HOW INJURY OCCURRED <br />DYES ONO <br />r~~__ --- <br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO. crTYITOWN <br /> <br />$1)!J'E <br /> <br />...ztf'1:lellE <br /> <br />>~ <br />~ <br /> <br />23a. DATE OF DEATH (Mo., Day, Yr.) <br /> <br />d Marc:h 8,2007 _..... ~U <br /> <br />il g! 'Ii >' ~ 24c. PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD <br />~~~ ~K~~ <br />a~~ e~~~ m <br />~ :6c 23d. To Ihe best of my knowledge, death occurred at the tlmo, date and place H ~ - 24e. 011 the basis of examination and/or investigation, In my opInion death occurred at <br />~ l!! and d~.elo th~'1u.a(.) ..t.at;.~".(Slgnature and Title) ,. /. ~ ~ 8 the 11m., date and pl.c. and due to tho Gauso(.) .tat.d. (Sign.ture .nd Title) ,. <br /> <br /><l )"1// 1\ /.:'J:\........~" J. f' 8 ~ <br />25. DIOTOBACCO USE CONTRIBUT TO THE DEATH? .. HA ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br /> <br />24a. DATE SIGNED (Mo., Day, Yr.) <br /> <br />24b. TIME OF DEATH <br /> <br />m <br /> <br />26b. WAS CONSENT GRANTED? <br /> <br />o YES jf_~~ 0 PROBABLY_.,0 UNKNOWN O,.YES ~NC:_~. <br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ' or Print) <br /> <br />Not.~pplleablolf 26al. NO .9. YES 0 N~. <br /> <br /> <br />28b. DATE FILEMAlr:Cr; (iooa, Yr.) <br /> <br />L <br />