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<br />STATE OF NEBRASKA
<br />
<br />~
<br />
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL Tf-!~AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASf<,f\r.,pii,AAf{7;MfiNT OF HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FO~lt~~ ~:~~!:'" ~ l
<br />
<br />DATE OF ISSUANCE :'.... "'e':4'o~
<br />JAN 3 0 2009 STl}rvLE'?s,cqoPErc' ", ': "
<br />ASSISTANr~ATE REGISTR(1.R.
<br />, o~p'AR~rrr;OF H~;4LTH~~N.~'
<br />HflMAN st~V.[(tI;S -"-t. ; '" ,"'
<br />~,\ ", .: (~'. ,."
<br />
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<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANqE AtolQ-$lJ~Jilh'}d.' : 't).-{"/''':>."'n 1
<br />CERTIFICATE OF DEATH 1 \.J !' . \j'~ @tJ...:TL..
<br />~ - '1 , .' f : ,r! ',. , '~. ~
<br />Last, Suffix) 2, SEX' \, ", ,3:'Diue OFD".AT~:,,(MIl., Day, Yr,)
<br />Kirkpatrick Male ~rtuar'y' '10, 2009
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />200901101
<br />
<br />(First,
<br />Eugene
<br />
<br />Middle,
<br />Edward
<br />
<br />Grand Island, Nebraska
<br />
<br />77
<br />
<br />
<br />6,DATE OF BIRTH (Mo" Day, Yr,)
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF 81RTH
<br />
<br />Sa, AGE.LaSl8lrthday
<br />(Y".)
<br />
<br />February 9, 1931
<br />
<br />7. SOCIAL SECURITY NUM8ER
<br />507-24-6428
<br />
<br />60, PLACE OF DEATH
<br />1:iQ.SflIAL:
<br />
<br />o Inpatient
<br />
<br />QllSl: XI Nursing Home/LTC 0 Hospice Facility
<br />
<br />~ACILITY-NAME (If not Institution, give slreet end number)
<br />
<br />o ER/Outpatient
<br />
<br />o Decedent's Home
<br />
<br />V.A. Medical Center
<br />
<br />o 0ClI\ 0 Other (Spacily)
<br />
<br />------. lSd, COUNTY OF DEATH
<br />~ Hall
<br />
<br />Iwt6~T:::d Island
<br />
<br />_", I"ge, APT NO ra,:-ZIP6C08D8E03
<br />2304 South Memorial Park Road L
<br />lOa, MARITAL STATUS ATTIME OF DEATH ~ Married 0 Never Married 10b. NAME OF SPOUSE (First, Middle, La,t, Suffix) It wile, glv. meiden name,
<br />
<br />Sc, CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />Grand Island
<br />
<br />68803
<br />
<br />l~~OUNTY
<br />
<br />Hall
<br />
<br />9g.INSIDE CITY LIMITS
<br />
<br />JO YES 0 NO
<br />
<br />Q Divorced 0 Unknown
<br />
<br />Joan Roggy
<br />
<br />11, FATHER'S.NAME (Firsl, Mlddla,
<br />Augustine F.
<br />
<br />La", Sufllx)
<br />Kirkpatrick
<br />
<br />12, MOTHER'S-NAME (First,
<br />Georgia
<br />
<br />Middle,
<br />P.
<br />
<br />Malden Surname)
<br />Jackson
<br />
<br />13, EVER IN U,S, ARMED FORCES? Give dete. ols.rvice II yes, 14e,INFORMANT.NAME
<br />(Y~~Ii!.ru~iI4/1951 2/3/1953 Joan Kirk
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />
<br />15, METHDD OF DISPOSITION
<br />ClBurial l:l Donation
<br />o Cremation [J Enlombrnanl
<br />
<br />16e EM~AIfER'SIGNATURE &.' -
<br />
<br />l1A ~rA. ~~
<br />16d. CEMETERY, EMATORY OR OTH LOCATION
<br />
<br />
<br />Wife
<br />
<br />16c. DATE (Mo., Day, Yr,)
<br />
<br />Januar
<br />
<br />15, 2009
<br />STATE
<br />
<br />CITY I TOWN
<br />
<br />o Removel 0 Olher (Specily)
<br />
<br />Phillips Cemetery
<br />
<br />Phillips, Nebraska
<br />
<br />(Stre.', Cily or Town, State)
<br />1123 West Second,
<br />
<br />Grand Island, NE.
<br />
<br />
<br />Zip Code
<br />
<br />PART I. Enter (he ~,ill"d.$ea~ee, injuries, or comptleati0!'l5--1hat direcrly caused tl"1e death. DO'NOt"E'riler ternilnalevenlS such as cardiac arreSI,
<br />respiratory arrest. Or ventricular fibrlllaliOl'l without showing the etlology. DO NOT ABBREVIATE. Enter only one cause on a line, Add additional lines If neoessary.
<br />IMMEDIATE CAUSE:
<br />
<br />onset to death
<br />
<br />IMMEDIATE CAUSE (Final
<br />(115ea5e or c::andlrlon i'@$ultlng
<br />Indealh)
<br />
<br />Sequentlellyllaleondlllons,II (b) presumed pneumonia
<br />any.leadlngtolhecau.ellsted -----OUETO, OR AS A CONSEQUENCE OF:
<br />on line e,
<br />Enterthe UNDERLYING CAUSE
<br />(dleee.. or injury thatlnltlet.d (e)
<br />~vent",esulllnglnd..th) DUE TD, OR AS A CDNSEQUENCE OF:
<br />
<br />--.!a)._~ardio pulm.onary failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />onsel to death
<br />
<br />onset to deatl'l
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Condilions contributing to Ihe death but not re.ultlng in the underlying cause glvan in PART I.
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />CaAdiomyopath cQ+onarv art~r ear t
<br />20. IF FEMALE: 21a, MANNER OF DEATH 21b, IFTRANSPORTATION INJURY 21c, WAS AN AUTOPSY PERFORMED?
<br />o Not pregnant within past year XI Natural CI Homicide 0 Driver/Operator
<br />
<br />o Pregnant at lime of death 0 AccidenlO Pending Invesllgatlon CI Passenger
<br />o Pedeslrlan
<br />o Nol pregnant, but pregnant within 42 day' 01 daalh 0 Suicida U Could nol be delarmined 21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Not pregnant, but pregnant 43 days 10 1 year belore deam 0 Other (Speclly) COMPLETE CAUSE OF DEATH?
<br />
<br />o unknowni,pregnantwllhln_thepastyear _ _~~_~ES 0 NO
<br />
<br />~DATE_ OF_IN::~MO , De~, Yr) _ 1_2~~~_E~F~:~UR: .22C' PLACE OF INJURY-AI home, lerm, streel,l.clory, olllce budding, con,truction site, etc, (Specily)
<br />
<br />22d INJURY AT WORK? --p2e DESCRIBE HOW INJURY OCCURRED ._~-, -- -----. ~ .
<br />DYES JP NO _I
<br />221. LOCATION OF INJURY" STREET & NUMBER, APT NO.
<br />
<br />YES
<br />
<br />~ ND
<br />
<br />DYES
<br />
<br />~ND
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />ne. DATE OF DEATH (Mo" Day, Yr.)
<br />
<br />J:anuarv to, 2009
<br />23b, DATE SIGNED (Mo" Day, Yr.)
<br />Januar 14, 2009
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />m
<br />
<br />~i~
<br />tJ,.
<br />~';<g
<br />oiz:~O
<br />uw~
<br />.!l~o
<br />,28~
<br />
<br />m
<br />
<br />23c, TIME OF DEATH
<br />13: 15
<br />
<br />24C, PRONOUNCED DEAD (Mo" Day, Yr.) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To the besl 01 my knowledge, death OCCurred althe time. dale and place
<br />and due 10 the cause(s) Slated, (Signature and TIlle) 'f
<br />
<br />/1--' c1t . ~ -
<br />
<br />246. On the basis 01 examination and/or Investlgallon, in my opinion death occurred at
<br />the time, date and pIece and due to the cause(s) staled. (Signature end Title) T
<br />
<br />26a, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />DYES 0 NO 0 PROBABLY IX UNKNOWN 0 YES !l ND Nol Applicable If 26al. NO 0 YES 0 NO
<br />27~iiiAME, TITLE ANO AODRESS OF CERTlFIER-(PHYSICIAN~ORDNER'S PHYSICIAN OR CDUNTY ATTDRNEY) (Type or Print)
<br />Patricia Cronin M.D.VA Medical Center 2201 N Broadwell Grand Island, NE 68803
<br />
<br />
<br />28b, DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />JAN J 1 2009
<br />
<br />~x. hi lit t- AI'
<br />
<br />HHS-61 11/03 (55061)
<br />
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