|
<br />STATE OF NEBRASKA
<br />
<br />
<br />1.DECEDENl'S-NAME (FI"'t,
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL TH A~~ SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASK~]j~f!Jf.EJ{t kif tiEACTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR, ~L'F~.k;,~~'f~ ~.i::! t;.
<br />
<br />DATE OF ISSUANCE ~v.~;
<br />20080937 t siArifj/s. co(jpt~ ......'::. Ii,
<br />Ass;;1Sr.ANTrqr{:fE REGjSTRAJ:?/,', >
<br />D~p4Tf1E!fJ.# dJi;~~1:!i AN.D,::' "'
<br />HiJ~~ ~ERVICES,,:'" _:,_;" ;,
<br />" ~.. '''''..1: "", 4 1'... ,.J
<br />RASKA DEPARTMENT OF HEALTH AND HUMAN SERVICes ", , '. (.'~, c:\ 'i"- " c,;) .~
<br />CERTIFICATE OFO'EATH' '; ,\'.;'i1:~~;'!.';.'~f~':{\a:.:,:
<br />2. SEX :~V'~II'Ii~f ~~ (1tO;,~!,Yi:r
<br />Male F~br'o*i- 260ft
<br />
<br />NOV 03 2008
<br />
<br />'?
<br />
<br />LINCOLN, NEBRASKA
<br />STATE OF NEB
<br />
<br />Mlddl.,
<br />
<br />Lillt,
<br />
<br />Suffix)
<br />
<br />Jackie Eugene Moore
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a. AGE-Loot Birthday
<br />(Y",.)
<br />
<br />)
<br />~
<br />Cl>
<br />
<br />Clearwater, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />75
<br />
<br />5b, UNDER 1 YEAR
<br />MOS. I DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS I MINS.
<br />
<br />I. OATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />March 16, 1932
<br />
<br />8b; FACILITY-NAME (Ir not Institution, give street and number)
<br />
<br />Ia. PLACE OF DEATH
<br />~ 0 Inp.tlenl
<br />o ER/Outpall.nl
<br />
<br />~ 0 Nurolng Homo/LTC
<br />iii Oecedenr. Home
<br />
<br />D Hooplc. Facility
<br />
<br />535-32-9525
<br />
<br />1308 N;'Parl( Ave,
<br />
<br />',-' - ~ --~~--e--,-".
<br />
<br />- QtodnIttSpecII)I
<br />
<br />',:
<br />w
<br />Z
<br />::I
<br />u..
<br />~
<br />1
<br />i
<br />
<br />QI
<br />Ci.
<br />E
<br />o
<br />U
<br />QI
<br />m
<br />{!.
<br />
<br />lie, CITY OR TOWN OF DEATH (Includ. Zip Cod.)
<br />Grand Island 68803
<br />
<br />I Bd. COUNTY OF DEATH
<br />Hall
<br />
<br />Nebraska
<br />
<br />19b. COUNTY
<br />Hall
<br />
<br />90. RESIDENCE.STATE
<br />
<br />1308 N. Park Ave.
<br />
<br />19C. CITY OR TOWN
<br />Grand Island
<br />19.. APT. NO. /Sf. ZIP CODE
<br />68803
<br />10.. MARITAL STATUS AT TIME OF DEATH iii Marrl.d D Neyer Marrl.d/10b. NAME OF SPOUSE (FI"'t, Mlddl., La.t, Suffix) If wll., glv. mald.n nom..
<br />o Married, but .ep..."'" 0 Wldow.d 0 Dlvorc.d 0 Unknown Sh.rt W b '
<br />I ey e er
<br />11. FATHER'S-NAME (Flret, Mlddl., Lael, Suffix) 112. MOTHER'S-NAME (FI~I, Middle, Mald.n Sum.m.)
<br />Thelma McVay
<br />
<br />/9g. INSIDE CITY LIMITS
<br />IKl Yo. D No
<br />
<br />9d. STREET AND NUMBER
<br />
<br />GeorQe Moore
<br />13. EVER IN U.S. ARMED FORCES? Glv. dot.. Of..,."lc.IIYeo.j14..INFORMANT-NAME
<br />(y.., No, or Unk.) Yes OS/25/1951-01101/1955 I Shirley Moore
<br />15. METHOD OF DISPOSITION 180.EMBALMER-SIGNATURE
<br />o Butial 0 Donation
<br />[iJ Cr1Imatlo", 0 EruombmerU
<br />o R.moviIIl 0 otntr(SJMlclfV)
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Wife
<br />
<br />Not Embalmed
<br />
<br />11Gb. LICENSE NO.
<br />
<br />
<br />CITYfTOWN
<br />
<br />15c. DATE (Mo.. Day, Yr.)
<br />
<br />February 11, 2008
<br />
<br />15d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />STATE
<br />
<br />Westlawn Memorial Park Crematory Grand Island
<br />
<br />170. FUNERAL HOME NAME AND MAILING ADDRESS (St",.~ City or Town, atate)
<br />Livingston-Sondermann Funeral Home, 601 N, Webb Road, Grand Island, Nebraska
<br />
<br />NebraSka
<br />,17b. Zip COd.
<br />68803
<br />
<br />CAUSE OF DEATH (See Instructions and examples)
<br />
<br />11. PARt I. Enter Ihlll ,;haln at.v.nts . diu.."., injUrilllB1 Dr camplICltlOnlll-lhBI dlnu:tly eluted Ihlll detrtr.. DO NOT .m.r "nnlna' ....n.. ,ue.h a, Un:liBG IImllt,
<br />....ph-etQil I.l"fHt, 1M Y81I1rto:ulat fibrlllMlan ~ iKtowh1O .....-.uoIoOlf. DOfttrf AII~ATI!=-etI.'r 6nty-,"CIInt ea..- Dft. line. Add addIUonIlll......'MC.....ry.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />, APPROXIMATE INTERVAL
<br />,
<br />I onset to d.ath
<br />I
<br />I
<br />:"unknown
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl..... or condition ",.ulllng jIt: card i ac a rres t
<br />In d.alh)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I onset to death
<br />I
<br />'"
<br />: 2 years
<br />
<br />Sequentially IIBt conditions, If
<br />any, leading to the eau.e listed
<br />on linlll B.
<br />
<br />'ll heart disease
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I oneet to death
<br />I
<br />,
<br />: unknown
<br />
<br />Enterth. UNDERLYING CAUSE c) 1 i ve rea nee r
<br />(diaeaB8 or Injury that InUI.led
<br />the ev.nl. ".ulting In d"'h) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />
<br />d)
<br />
<br />I Onlllllet to death
<br />I
<br />,
<br />I
<br />I
<br />
<br />~. PART II, OTHER SIGNIFICANT CONDITIONS-Condllion. conl~bullng 10 the dealh but not re.ulllng In th. und.~ylng cau.. glyon In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />liU YES 0 NO
<br />
<br />II:
<br />W
<br />ii:
<br />~
<br />w
<br />u
<br />~
<br />~
<br />QI
<br />Ci.
<br />E
<br />o
<br />(j
<br />f>>
<br />-m-
<br />o
<br />.....
<br />
<br />20, IF FEMALE:
<br />o Not pregn.nt wllhln pe.t yoar
<br />o Pregnant at lime 01 daeth
<br />o Not pr.gn'n~ bul preynonl within 42 dey. of d..1h
<br />o Not pregnant, but pngnant 43 Clays to 1 yellllr before death
<br />D Unknown II pregn.nt within th. pe.t y..r
<br />
<br />;.1.10. MANNER OF DEATH
<br />[):Nalural 0 Homlcld.
<br />o Accld.nt 0 P.ndlng Inv..tigotlon
<br />OSulcld. D Could nol b. dotarmln.d
<br />
<br />21b. IF TRANSPORTATION INJURY
<br />o Driyer/Operetor
<br />o P....ng.r
<br />D Pod.'lrlan
<br />o Olher (SP'Cify)
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />D YES iii NO
<br />
<br />,,31d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />DYES ~NO
<br />
<br />220. DATE OF INJURY (Mo.. Day, Yr.) I 22b. TIME OF INJURY I22C. PLACE OF INJURY-At hom',I.rm. otroot. f.Clory, office building, con'lrucllon .,t., .,c. (Sp'Clfy)
<br />
<br />
<br />"d. INJURY AT WORI(7<r'O' DESCRIBE'HOW INJURY'OCCURRED
<br />DYES ONO I
<br />
<br />221. LOCATION OF INJURY -STREET I. NUMBER, APT. NO.
<br />
<br />"ITYfTOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />p
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />I...~ ...~~
<br />E~ ~uz
<br />'ll ,ft J 'tl iii 0::
<br />~ ~ >- 23b. DATE SIGNED (Mo.. Day, Yr.) 23c. TIME OF DEATH m ~ ~ ~ >-
<br />o"a.....J o.t ...
<br />5C11cZO El'l<l:Z
<br />o o::t 0
<br />I! :a 23d. To the best of my knowledge, death occulllJd at the time, date and place ~ &1.1 !i 2f:; On lhe ballil. of e.amlnaUon anellor Irw.'tlgaUon, In my opinion dellth occurTed
<br />~ !Ii and du.,o the couee(.) .lat.d. (Signature and TIll.) ~ Z::l at lh.,lm., data and plac. and due 10 lhe cau..(.)atal.d. (Signature .nd Tille)
<br />:B ~ ~8 '/rv( ./'1
<br /><I: 8 ~ '/i.:./ ~ J _ Hall County Attorne
<br />
<br />~ DID TOBACCO USE CONTRiBUTE TO THE DEATH? I~. HAS ORGAN OR TISSUE 0, 0, NATION BEEN CONSIDERED?, r=:z~ .~ AS CONSENT GRANTED?
<br />DYES 0 NO 0 PROBABLY ~ UNKNOWN I 0 YES 12l" N? /f"Not Applicobl. If 2801. NO 0 YES 31 NO
<br />
<br />TLE AND ADDRESS OF CERTIF~(PHYSICIAN, CORONER'S PHYSICIAN ~UNTY ATTOR~TYpe or Prlnt) Y
<br />
<br />Mark J. Youn". Hall County Attornev, 231 S. Locust St. Grand Island NE 68801
<br />210. REGISTRAR'S SIGNATURE k J ~ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />, ... 'j "~A'o JJ. ~ ~.,. FEB ! 7 2008
<br />V
<br />
<br />~. DATE BIGNED (Mo., Dey, Yr.)
<br />
<br />February 20, 2008
<br />
<br />,J1b. TIME OF DEATH
<br />12:01
<br />
<br />pm
<br />
<br />~. PRONOUNCED DEAD (Mo., Day, Yr,) ~. TIME PRONOUNCED DEAD
<br />February 9, 2008 2: 40 p m
<br />
<br />\
<br />
<br />~
<br />(~
<br />
<br />'---'
<br />
|