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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH~fVfJ.H~SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH THE NEBR~/~kA qlifWf.rf;faf/;rbf, HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR'VIT(rt,\fi.~CORD$:'- /1. II
<br />
<br />~'c::.""~"t::~,,"1
<br />" ... r' ~ ...., ~,
<br />DATE OF ISSUANCE "0' ..' _. _~ ' ~' .'
<br />2 0 0 8 0 8 9 5 5 STAbJL.fYi S. COOPER ,'" '- .... /
<br />AS~~TA'r-.e~TtfJASGfSTR4(J. :.~
<br />DE~?<.R.rMM ~4c1'H AJV!J. .;
<br />LINCOLN, NEBRASKA HUMA/V. SERVIG; '"" : /, :)
<br />STATE OF NEBRASKA. DEPARTMENT OF HEALTH AND HUMAN SERVICEs', 1''<-'1 ,.~,:~,.-::.,: ~.:' ,~ 08 01261
<br />CERTIFICATE OF DEATH ,'", . ,', '-' n , ",,' . .' _'\ l< ~:
<br />
<br />09/18/2008
<br />
<br />Amended
<br />
<br /> ~,l ~ .- , "
<br /> 1. DECEDENrS.NAME (First, Middle. Last, Suffix) 2. SEX ' " 3. 'DATE OF t>EPt'Ri (Mo.. Day, Yr.)
<br /> , , , , I. ...:..
<br /> Jimmie L Essink Male , September 1,' 2008
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE. Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. I DAYS HOURS I MINS.
<br /> Panama, Nebraska 67 March 14, 1941
<br /> 7. SOCIAL SECURITY NUMBER 6a. PLACE OF DEATH
<br /> 505-54-2283 ~ ~ Inpatlenl QI!::\EB 0 Nursing HomelL TC o Hospice Facility
<br /> 8b. FACILITY.NAME (If not Institution, give street and number) o ERlOutpatlent o Decedent's Home
<br />ll::
<br />0 BryanLGH Medical Center East DDOA D Other (Specify)
<br />l-
<br />I.)
<br />W 8c. CITY OR TOWN OF DEATH (Include Zip Code) 16d. COUNTY OF DEATH
<br />D:
<br />i:i Lincoln 63506 Lancaster
<br />..J 9a. RESIDENCE-$TATE 19b' COUNTY 19C. CITY OR TOWN
<br />~
<br />w Nebraska Hall Grand Island
<br />z
<br />:::l 9d. STREET AND NUMBER reo APT. NO. 191. ZIP CODE 199. INSIDE CITY LIMITS
<br />l&. 524 E. Meves Avenue [j YES D NO
<br />~ 68801
<br />al 10a. MARITAL STATUS AT TIME OF DEATH [gI Married 0 Newr Married 110b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />IE o Married, bulseparated D Widowed D Divorced D Unknown Carole Samek
<br />i 11. FATHER'S-NAME (Flrsl, Middle, Last, Suffix) 112. MOTHER'S.NAME (Flrsl. Middle, Malden Surname)
<br />Edward Essink Mary Shaw
<br />Q. 13. EVER IN U.S. ARMED FORCES? Give dates 01 esNlce If Yee. 114a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />8 (Yes, No, or Unk.) No Carole Essink Wife
<br />11 is. METHOD OF DISPOSITION 18a. EMBALMERoSlGNATURE I 16b. LICENSE NO. 16c. DATE (Mo" Day, Yr.)
<br />[!. IX! Burial D Donallon William M. Cicmanec 1036 September 5, 2008
<br /> D Cremation D Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br /> D Removal o other (Specify) Grand Islarid City Cemetery Nebraska
<br /> Grand Island
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreet, City or Town, Stale) /17b. Zip Code
<br /> Curran Funeral Chaoel 3005 S. Locust St., Grand Island Nebraska 68801
<br /> CAUSE OF DEATH ISee Instructions and examDlesl
<br /> 18. PART I. Enter the chaIn or IIVIlIIt.. -ell......., InJurl.., or compllatlons-that dl...ctly aa.....d the death. DO NOT enter terminal evenh such at cardl.ac .1......81:, APPROXIMATE
<br /> INTERVAL
<br /> re.plratory 1iIIrT8I1t, or ventrleul.r fibrillation whhout showing the etiology. DO NOT ABBREVIATE. Enter only on, Coal.!"- on allnllll. Add IIIddltlonallln..lf n8C8Bl.lry.
<br /> IMMEDIATE CAUSE: onset 10 death
<br /> IMMEDIATE CAUSE (Final a) Pulmonary Embolism Hours
<br /> dlSflilS. 01' COnditiOn ....lImlti....u
<br /> In Goath) DUE TO, OR AS A CONSEQUENCE OF: onset 10 death
<br /> Sequentially 1101 cond~lono, It b)
<br /> any. loading to the cau.. lIotod
<br /> on line ..
<br /> DUE TO, OR AS A CONSEQUENCE OF: 008elto death
<br /> Entor lhe UNDERLYING CAUSE C)
<br /> (disease or Injury that Initiated
<br /> the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onsello dealh
<br /> LAST d)
<br /> 16. PART II. OTHER SIGNIFICANT CONDITIONS.condlllons contrlbullnglo the death bul nOI resulllngln the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br />ll:: DyES [gI NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b.IF TRANSPORTATION INJURY 21<:. WAS AN AUTOPSY PERFORMED?
<br />ii:
<br />~ o Not pnlgmmt within pal1. yeil' l:&I NolItural o Homicide o Drfv8r/OperatDr DYES [gI NO
<br />W o PreUn.lnt lit time or death D Accldont o Pending In'leetloa.lon o P...nu.r
<br />I.)
<br />~ o Not pregnant. but pregnant within 42 dlillY. of d.ath o Suicide o Could not be determined D Podoot~an 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />D Not pregnant. but prevnant 43 Gays 10 1 yo.r bSfore Go.t~ D other (Spaclly) TO COMPLETE CAUSE OF DEATH?
<br />~ o Unknown Ir pnlignlillnt within the p.. y..r DYES D NO
<br />Q. 22a. DATE OF INJURY (Mo., Day, Yr.) 122b. TIME OF INJURY I 22c. PLACE OF INJURY.At home, larm, street, factory, office building, construction site, etc. (Specify)
<br />E
<br />0
<br />u
<br />11 22d. INJURY AT WORK? r2e. DESCRIBE HOW INJURY OCCURRED
<br />[!. DYES ONO
<br />" 22'. LOCATiON OF-tNJI;IIl.Y-' ST-RfET" NliMBeR,- APT;NO. ' '----~~- ..~-- -- ----". "1'Afl!' c~~ "--",~,, -- '-- , ' ' - ZIP COOE
<br /> 238. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGM:D (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> ~~ September 1, 2008 .f~ti
<br /> i~>- 23b. DATE SIGNED (Mo., Day, Yr.) I 23c. TIME OF DEATH I!~~ 240;:. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> iD.~ September 4, 2008 08:33 AM
<br /> !,O 2Sd. To the best of my knowledge, delillth occurNd at the tlmII, dlilll. and place ~i~~ Z4t. On the balla of ....ml...atlon and/or Inv....lgatlon, In my opinion deilth occurred
<br /> ilt
<br /> J li IiIInd due to the CIiIIUse(B) atated. (Signature and Title) the tlrM, dau .nd place and due to the GaUM(.) ttated. (SIGnature and Tltl.)
<br /> ~ ~ olu
<br /> Tamer Mahrous, MD .... i5
<br /> 2S. DID TOBACCO USE CONTRIBUTE TO THE DEATH? \26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? I 26b. WAS CONSENT GRANTED?
<br /> DYES [gI NO D PROBABLY D UNKNOWN I&l YES 0 NO Not Applicable If 28a Is NO 0 YES [gI NO
<br /> Z7. NAMI:, . '" ype or ..r nil
<br /> Tamer Mahrous, MD, 2300 S 16th, Lincoln, Nebraska, 68502
<br /> 28a. REGISTRAR'S SIGNATURE ~ "<- .., I 28b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.)
<br /> ...<0.. ~tLt.{' September 8, 2008
<br />
<br />Amended
<br />9/18/2008 Item 3. 238
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