|
<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 />
|