|
<br />STATE OF NEBRASKA
<br />
<br />,
<br />
<br />,
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENTOF HEAlJf.1'i~\WMAN SERVICES/ IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEi~RAQ<t1~i!PIV~l~ENr.OF HEALTH AND
<br />HUMAN SERVICES/ VITAL RECORDS OFFICE/ WHICH IS THE LEGAL DEPOSITORY~~.. R<:.:.vt.r.I}.~ ~,t. ~1&'. O. ittJ.. .,....is'..;'.... i i
<br />~:"h-~~'..~. t: 'r:L- '1.., __
<br />DATE OF ISSUANCE ':<: ~~~i:':":~~
<br />
<br />JA N 2 7 2009 200 90 10 4 4 .; ~'-~rs7gXi~'g~orf~~!~TR1R
<br />. 1!.5fAFtrM$41' OF Ffl!/fL Tr[:,Ar;D
<br />LINCOLN/ NEBRASKA ii, I:fJ.!TYfAry S€RUlqes, . .: ",' ,-'
<br />rl' ~i \'~.l( ".... .I.b'~(~'i] ~':,' ;."j.._: '..:' >-'>"~_ ~.J, ~,~;.,!
<br />.; ~~(.,' f~f,' \ ~.,.
<br />~. U ;:~ '.... - J .',',,1 ~
<br />~ ~ I'l i j. I J ' I \ (."1 ~ j'" \...' .....
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AN~ ~'~~~~.. "'2" ""'3""-18 8
<br />___' CERTIFICATE Of DEATH __.U 0 '
<br />
<br />
<br />Lyle W. DA
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />50. AGE.La.t Birthday
<br />(Yro,)
<br />
<br />
<br />D
<br />
<br />
<br />1. DECEDENT'S-NAME (First,
<br />
<br />Middlo,
<br />
<br />La.st,
<br />
<br />SUlli')
<br />
<br />Gothenbun:. Nebraska,
<br />7, SOCIAL SECURITY NUMBER
<br />
<br />,61
<br />80, PLACE OF DEATH
<br />
<br />,~_ _. 507-60-515A
<br />Sb. FACILITY-NAME (If not Institution, give street and number)
<br />
<br />1::lO..SfJIAJ.,
<br />
<br />[J Inpatient QlliE8: [J Nursing Home/LTC 0 Hospice Facility
<br />
<br />Q ER/OutpatiBnt ~DeCiedent's Home
<br />
<br />203 Leisure Lake Road
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />Cl 0Cl\ Cl Other (Specify)
<br />18d. COUNTY OF DEATH
<br />HAll
<br />
<br />90, RESIDENCE.STATE 9b. COUNTY
<br />
<br />NebrAskA_~
<br />go, STREET AND NUMBER
<br />
<br />,203 Leisur. Lake Road
<br />100, MARITAL STATUS AT TIME OF DEATH O[Marriod Cl Novor Mo'ri.d
<br />
<br />I ge, CITY OR TOWN
<br />I
<br />
<br />
<br />gUlP CODE
<br />
<br />9g.INSIDE CITY LIMITS
<br />
<br />Cl YES Q( NO
<br />
<br />68832
<br />1 Ob, NAME OF SPOUSE (First. Middle, Lasl, SUlllx) If wife, give maiden name.
<br />
<br />o DivorCed 0 Unknown
<br />
<br />. BarD Stein
<br />
<br />Middlo,
<br />
<br />Lo.t,
<br />
<br />SUffl')
<br />
<br />12. MOTHER'S.NAME (First,
<br />Louise
<br />
<br />Middlo,
<br />
<br />Malden Surname)
<br />
<br />VerI n
<br />13, EVER IN U.S. ARMED FORCES? Givo dO to. ol.orvie. if yos,
<br />(Yes, no, or unk.) . :t!O
<br />15. METHOD OF DISPOSITION
<br />~Burlal Cl Donetion
<br />Cl Cremation Cl Entombmont
<br />
<br />Cl Removal Cl Othor (Specify)
<br />
<br />
<br />Johnson
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />1189
<br />CITY I TOWN
<br />
<br />Wife
<br />160. DATE (Mo., Day, Yr. )
<br />
<br />March 4.Q 2008
<br />STATE
<br />
<br />16b.lICENSE NO.
<br />
<br />Parkview Cemetery
<br />
<br />17., FUNERAL HOME NAME AND MAILING ADDRESS (Stroet, City or Town, Stato)
<br />
<br />
<br />Has tings
<br />
<br />Elm Avenue
<br />Nebraska
<br />
<br />Nebraska
<br />
<br />17b, Zip Code
<br />
<br />PART I. Enter the maln...Ql,~,Y:,ll'fla"-dj$ea$e$, Injuries, or comDlicalionsulhal direr"lly caused the dealh. DO NOT P.ilter terminal events such ~!,; cardiac: arrest,
<br />respIratory arrest. or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add addlllonalliliEt5 it nEtcessary.
<br />
<br />
<br />APPROXIMATE INTERvAL
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />on..t to death
<br />
<br />IMMEDIATE CAUSE (Rn.1
<br />dl.....oreondttiBn _ulllng
<br />In_)
<br />
<br />· natural causes associated with old aqe
<br />DUE TO, OR AS A CONSEQUENCE OF;
<br />
<br />immediate
<br />
<br />on.ot to d..th
<br />
<br />Soquontlally lI.t condition., II (b)
<br />any, leading 10 tho caUH lI.led DUE TO, OR AS A CONSEOUENCE OF:
<br />on IIn..,
<br />Enter the UNDERLYING CAUSE
<br />(dl.oa.e or Injury th.t Inltlelad (c)
<br />:r-nta _unlng In doalh) DUE TO, OR AS A CONSEQUENCE OF;
<br />
<br />onset 10 death
<br />
<br />onsel to dealh
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITlONS.Condilion. contributing to tho daalh but not rasul1lng in Iha undorlying causa glvon in PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />Xl YES Cl NO
<br />
<br />20, IF FEMALE.
<br />Q NOI pregnant within past year
<br />a Pregnant at time 01 death
<br />o Not pregnant, but pregnant within 42 days of death
<br />o Not pregnant, bur pregJ'l8.nt 43 days to 1 year before death
<br />Q Unknown if pregnant within the pasl year
<br />
<br />21a. MANNER OF DEATH
<br />Xl Natural 0 Homicide
<br />
<br />Cl AcoidanlCl Ponding Invasligatlon
<br />
<br />21 b.IF TRANSPORTATION INJURY
<br />Q Driver/Operator
<br />
<br />IJ poaaanger
<br />
<br />Cl Podastrian
<br />
<br />Cl Olhor (Specily)
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />Cl YES Cl:NO
<br />
<br />o Suicide 0 Could nol be delermined
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABlE TO
<br />COMPLETE CAUSE OF DEATH?
<br />Cl YES ~ NO
<br />
<br />Cl YES Cl NO
<br />
<br />
<br />22.. DATE OF INJURY (Mo., Day, Yr,)
<br />
<br />22b. TIME OF INJURY 220, PLACE OF INJURY.At homo, farm, st,o.t, factory, ollico building, con.tructlon site, ole. (Specily)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER. APT. NO.
<br />
<br />CITYfTQWN
<br />
<br />SWE
<br />
<br />ZIP CODE
<br />
<br />230, DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />240, DATE SIGNED (Mo., Day, Yr.)
<br />March 21.!_}008
<br />
<br />24b, TIME OF DEATH
<br />
<br />m
<br />
<br />z,..
<br />~~!l!
<br />H~
<br />Q.D. 4( ::.
<br />eH~
<br />.!l~8
<br />,2a:U
<br />815
<br />
<br />1:00
<br />
<br />am
<br />
<br />23b, DATE SIGNED (Mo.. Day. Yr.)
<br />
<br />230, TIME OF DEATH
<br />
<br />24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To the best of my knowledge, death occurred at the lime, dale and place
<br />and due 10 the cause{s) stated. (Signature and Tille) ...
<br />
<br />25, DID TOBACCO USE CONTRIBUTE TOTHE DEATH?
<br />
<br />26.. HAS ORGAN OR TISSUE DONATIO
<br />
<br />Not Applicable if 260 is NO 0 YES Cl NO
<br />
<br />Locust St.
<br />
<br />Grand Island
<br />
<br />
<br />26b, DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />MAR 2 8 2008
<br />
|