|
<br />STATE OF NEBRASKA
<br />
<br />. WH"EN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL TH AND HUMAN SERV~CES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEifRASKA DEPARTMENT OF HEAHH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR .VL.~tlo~~" ". ....
<br />
<br />DATEOFISSUANCE .,' ..\ ,.' ,~l:ll?~,
<br />~'SrAi')JL'Ef... cfPf:j<. .'<~ I
<br />. ~SSIS-rANL!irJ TE f?EG.IB'f~
<br />.~ (iEPARTMENT OF HEAL ttf~Np
<br />" ~UMA&~PtL.'" : ::~ .J
<br />
<br />':. t\.. '-~,;::--'::~J5.;.:~~ ;,~
<br />
<br />~, . 1'....-'" ' ",. ._
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC~S ~,~~~~[)flG'~;': ~\ *..;;"
<br />H' CERTIFICATE OF DEATH . ~ JU' Y ",.
<br />1. DECEDENT'S.NAME (Firsl. Middle, Last, Suffix) 2. SEX.3cDATE OF DEATH (Mo" Day, Yr.)
<br />James Brian McElro Male 8-8-2008
<br />4. CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH Sa. AGE.Lasl Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Me.. Day, Yr.)
<br />(Yrs.) MOS. DAYS HOURS MINS.
<br />55
<br />
<br />AUG 2 8 2008
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />200810447
<br />
<br />JJ
<br />
<br />
<br />
<br />Columbus. Ohio
<br />
<br />March 23. 1953
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />506-60-6836
<br />
<br />8a. PLACE OF DEATH
<br />
<br />1iO.SfJJAL.:
<br />
<br />Cl Inpallant
<br />
<br />QIIJE8; Cl Nursiny Home/LTC Cl Hospice Faciilly
<br />
<br />(II nol In5l1lullon. give stre.1 .nd numb.r)
<br />
<br />Cl ER/Outpalient
<br />
<br />CJ D.c.d.nl's Home
<br />
<br />2.5 miles S. of Anselmo: Anselmo Rd.
<br />
<br />OlDl
<br />
<br />IXl Olh.r(Spoclfy) Anselmo RD
<br />
<br />Bd. COUNTY OF DEATH
<br />Custer
<br />
<br />8c. CITY ORTOWN OF DEATH (Include Zip Code)
<br />Anselmo 68813
<br />
<br />9a RESIDENCE-STATE
<br />Nebraska
<br />
<br />9b. COUNTY
<br />Hall
<br />
<br />
<br />9f. ZIP CODE
<br />68824
<br />
<br />9g.INSIDE CITY LIMITS
<br />
<br />o YES Xl NO
<br />
<br />9d. STREET AND NUMBER
<br />8270 Equus' Lane
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH IXl Marri~';-6 Never Married
<br />
<br />lOb. NAME OF SPOUSE (First. Middle, Lasl. Sulflx) If wile, giva maiden nam..
<br />
<br />o Married, but separ.t.d 0 Widow.d 0 Divorced 0 Unknown
<br />
<br />Devra Weber
<br />
<br />11. FATHER'S.NAME (First,
<br />James
<br />
<br />Middle, Last.
<br />L. M'?-:Elroy
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S-NAME (First. Middle.
<br />Rosemarie Bates
<br />14b'. RELATIONSHIP TO DECEDENT
<br />
<br />Maiden Surname)
<br />
<br />15. METHOD OF DISPOSITION
<br />JO Burial 0 Donation
<br />Cl Cremallon 0 Entombmenl
<br />
<br />
<br />MC~
<br />==-___mCb/~I~~N;E2NO.
<br />
<br />HER LOCATION CITY I TOWN
<br />
<br />Wife
<br />lBc. DATE (Mo., Day, Yr. )
<br />Au us t 1.1." 2008
<br />STATE
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dales of s.rvlc. if y.s. 14a.INFORMANT-NAME
<br />(t.f#,~.or~/)23/ 1972-2/5/ 197
<br />
<br />o Removal 0 Other (Sp.cify)
<br />
<br />_. Grand Island Ceme~ery
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slr..t, City or Town, Slate)
<br />Apfel Funeral Home 1123 West 2nd St. Grand
<br />
<br />PART I. Enler the cIlain..Ql.aY.WIll--dis....s, injuri.s, or complications--that directly caused the d.ath. DO NOT .nler lerminalevents such as cardiac arre.t,
<br />re.piralory .rr.st, or ventricular fibrillation without showing Ihe etiology. DO NOT ABaREVIATE. Enter only one cause on alin.. Add additionallin.s if n.cessary.
<br />
<br />
<br />Grand Island. Nebraska
<br />
<br />17b. Zip Code
<br />
<br />68801
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onset to dealh
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />dl..... or condition resulting
<br />In death)
<br />
<br />(a) Head Trauma
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />:Immediate
<br />
<br />onset to d.ath
<br />
<br />Sequentially tI.1 conditlono.1f
<br />any, leadlnylo the couea listed
<br />on IIn. B.
<br />Enterthe UNDERLYING CAUSE
<br />(dl..oea 0' InJUry thot Initiated
<br />lhe ....nt. resultlny in _h)
<br />LASI"
<br />
<br />(b) Motorcycle~<::~ident
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on..tlo death
<br />
<br />(d)
<br />
<br />lB. PART II. OTHER SIGNIFICANT CONDITIONS-Condition. contributing to the de.th bul nol r.sulliny in Ihe underlying cause given In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />~ YES 0 NO
<br />
<br />20. IF FEMALE:
<br />
<br />21a. MANNER OF DEATH
<br />o Nalural 0 Homicide
<br />
<br />~AccldonlCl P.ndlng Inveollgation
<br />
<br />o SulCid. 0 Could not be delermlned
<br />
<br />21b.~TRANSPORTATION INJURY
<br />a Driver/Operator
<br />
<br />o Passenger
<br />
<br />o Pedestrian
<br />
<br />o Othor (Speclly)
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />o YES ~NO
<br />
<br />o Not pregnant within past year
<br />o pregn.nt at tlmo of dealh
<br />CJ Not pregnant, but pregnant wllhin 42 days of dealh
<br />Cl NOI pregnanl. but pregnanl43 days 10 1 y.ar b.for. d.alh
<br />o Unknown if pregnant within Ih. pa.t y..r
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLETO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />22a. DATE OF INJURY (Mo.. Day, Yr.) 22b. TIME OF INJURY 22C. PLACE OF INJURY-At home, larm, streel, faclory. office building, con.truction sit., .Ic. (Sp.cify)
<br />August 8, 2008 7:00 P m County Road
<br />
<br />22d.INJURY AT WORK? 122;. DESCRIBE HOW INJURY OCCURRED 11 .
<br />Ro ed b1ke and landed on top of him.
<br />DYES ;j.NOIDecedentwas Driving Motorcycle__&_____!2~!_.c::g.ntrol.
<br />
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITYITOWN STATE ZIP CODE
<br />
<br />2.5 miles south of_..J.I.,nselmo on Anselmo Iic;l.~ Anselmo
<br />23.. DATE OF DEATH (Mo., D.y, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.)
<br />~~i:i 8-18-08
<br />
<br />J~~~
<br />r~~~
<br />ll~iS
<br />,2~~
<br /><.>0
<br />
<br />NE
<br />
<br />68813
<br />24b. TIME OF DEATH
<br />7:00 P m
<br />
<br />23b. DATE SIGNED (Mo.. D.y. Yr.)
<br />
<br />23c. TIME OF DEATH
<br />
<br />m
<br />
<br />24d. TIME PRONOUNCED DEAD
<br />7:05 A m
<br />
<br />23d. To Ihe b.st 01 my knowl.dg., d.ath occurred atlhe time. date and place
<br />and due to the cause(s) stated. (Signatur. and Titl.) ..
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />Not Applicabl~~i.f_26a is NO 0 YES 0 NO
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />Broken Bow,
<br />28b. DATE FILED BY REGISTRAR (Mo., Day. Yr.)
<br />
<br />E
<br />2
<br />
<br />AUG 2 6 2008
<br />
|