|
<br />STATE OF NEBRASKA
<br />
<br />"01...... "''ll "'~ ". ,
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF H. EIJ;LitR.. '. ....l'ofVa. ..... IfI.j!j M.. ~~ ~. ~RVICES, IT CERTIFIES
<br />:~~~L~;;'~i'c:%, AVlr;,,~ER~'r;.g~ 6~~1~~~":t~;g'ii~~ f:O;:Lg;g:IT'b':yNF~~r~;j;i7EAL TH AND
<br />
<br />DATE OF ISSUANCE~!~',:,~, ,
<br />
<br />MAR 0 9 2009 200902 212 ;f~~:~gA~1~~Gtsi~~:
<br />?e;~eTMENr IOF'HEAL TI-l #;0'
<br />LINCOLN, NEBRAS~:~ OF NEBRASKA- OEPAflTMENTOF HEALTH AND HUMAN SERVI~~t;;;t~~~.~ii.? 2 t1 597
<br />CERTIFICATE OF IJEATH ''\, <) t :.... ~:2'_'_.___.:._~-,-_
<br />-~~';CED~NT'S'N~i"E;r~'I. ... --'~~i~d~~~---'''~~;l~;~'~-~~--'- - -'sui;;~;- ~-"'"---~!(f~;:0~:~4-ipAtttA71i/"~ :loot~
<br />
<br />,.--.+-----~,.._"~~~- -~.~-~~_._-_.,----~....__.._..".~-'- ~
<br />
<br />)
<br />i
<br />i
<br />
<br />
<br />4. CITY AND STATE 011 TERIlITORY. OR FOIlEIGN COUNTRY OF BIRTIi
<br />Dannebrog, Nebraska
<br />
<br />5. AClE.l." B"lnd.~ . Sb UNDEFl1 YEAR Sc UNOER 1 DAV 6. DATE OF BIRTH (1.10.. O'r. Y!.\
<br />tY.&) 76 '-i..clli'- D~ys--~-HciuFis-:--MiNS-~ Nov. 1 2, 1929
<br />
<br />~"---'~~"'_I--------~~
<br />
<br />. ~A.I'lACE Of DEAl}-!
<br />
<br />7. SOCI...L SECURrTY NUMBEIl
<br />507-38-6241
<br />
<br />:J Inp.".nl
<br />
<br />onm
<br />
<br />::J Nuos.rtQ IlOIne!lTC :J Hospjc. F.eihly
<br />
<br />IiQsEillJ.
<br />
<br />]
<br />
<br />i
<br />I
<br />I
<br />j
<br />
<br />8b. F~CIL1TV.NAt.lE (II nol inSlilul,on. giyl slleel aM numO."
<br />
<br />:2J ERIOulplllOnl
<br />
<br />(J Decedel\l'aliOme
<br />
<br />St. Francis Medical Center
<br />
<br />:J!X)l.
<br />
<br />U Olhe< (speoryJ
<br />
<br />Bc. CITY OR TOWN OF DEATIi Ilnclud. Zip Codel
<br />
<br />Grand Island 68603
<br />
<br />8<1. COUNTY OF OEllTli
<br />Hall
<br />
<br />, ill. COI..MV . 9<:. C1TV on TOWN
<br />Hall Cairo
<br />..~-,-"~-,,.,...~--~---'--'~--~~-
<br />9. ...PT. NO
<br />
<br />!la. RESlDENCE.STATE
<br />Nebraska
<br />lid. STREET ANO NUMBER
<br />Medina
<br />
<br />i 9UIP COOE
<br />68824
<br />
<br />! 9a.INSIOE CITYlIIJITS
<br />31 YES :J NO
<br />
<br />101. MARIT...t STATUS AT TIME OF OEAlli m MI"ild 0 N.,., M.rt,ed '100. NAME OF SPOUSE IFltS!. Ml(,ldll. Last. Sulfi.) 1I""e, gIVe maiO'. name.
<br />
<br />:J Diyo.ced 0 Unkno"n
<br />
<br />Margaret Krajewski
<br />
<br />Middle. last 5ulliol 12. MOIHER'S.NAME (Forst
<br />Harry H. Fr ies __________~l!_ce .
<br />13. EVER IN U.S. ARMED fORCES? Gin dal.. ol.."icl ., )1s. '....INFORUANI-N...ME
<br />(Yes,no,orunk.' Yes2/13/S2-1/21 /5;4~largare~_Xr"ie~
<br />IS. M"HOD OF"oISPOSITION : 16a.E~~~~RE /J f.... 1Gb LICENSE NO.
<br />]ClBunal :lDollal",n ' ~.GdJtl!1#h 913
<br />:J CMnlltiOtI :J Enlombmlnl ,16d. CEMETERY, CREM"TOIlY DR OTflER lOCATIl);" 21----- CITY I TOvm
<br />iOakridge Cemetery Dannebro9,
<br />:J R.......I QOth.ttSllKi!y"
<br />
<br />i "__.______.______~"_____.__.__~__.____
<br />17,. FUNERAl flOME NAME AND M~IUNG ADDRESS (St...1. City o.Tg"n. Slalei
<br />Jacobsen-Greenway'Funeral Home-P.O.
<br />
<br />I,laidtn Sutnaml)
<br />
<br />Middle,
<br />
<br />Myers . __~'-----~
<br />! Ub, RElATlOr.iSHIP TO DECEDENT
<br />i Wi fe
<br />i 16<- o...TE 11.10.. a.r. Yr. )
<br />~pril 12.. 2006
<br />
<br />STATE
<br />Nebraska
<br />
<br />i&. PAfi"L Emer me cnaln 01 ~l1t5--dilit;jd:illi5. ir~jur_. O(C;~,'it~i"'O:Ii1J(.r.I~.~=t d'i"t~tli" .;;a~:;I~ 1!'1. ::lU~ co ~JO"!' 1!!!'1,!r 1.1!fmll"l~t iP.V'!'*, 'i!Jr.~ It$ c.atdiar.:
<br /> """l
<br />'.sp''''IOry a"..I.ol _riculo,fibrillolionwiihwlshOWlngllle e""logr. DONUT ABBRl<VIATE.Enlerpn'y on. cau.. 0'1,'1,,,". AIId a5d'I;oo.I.I,,,"' it neo<!SU'Y.
<br />
<br />!
<br />
<br />i
<br />I
<br />I.
<br />I
<br />I
<br />I
<br />----1.
<br />I
<br />I
<br />I
<br />
<br />It.tMEDI4TE CAUSE:
<br />
<br />0....110 death
<br />
<br />,., Cardiopulm~,~~.ry arrest
<br />DUE TO. 011...5 A CONSEQUENCE OF:
<br />
<br />'30min
<br />
<br />0_ to dum
<br />
<br />........,.liIt~.W
<br />..,.__IOII1Ic..... _
<br />...lIne ..
<br />_"~'IIIG_ .
<br />(~or~lhIIl"'"
<br />..__-....iII_1
<br />..-
<br />
<br />~ Chronic renal failure.
<br />DUE TO. OR AS A CONSEQUENCE oR'''''.-
<br />
<br />unknown
<br />
<br />0...110 dlllh
<br />
<br />(e)
<br />CUE TO. OR AS A CONSE~UENCE OF:
<br />
<br />0_ 10_11
<br />
<br />/d)
<br />lB. PA!lT ItOTIiER SIGNIFICANT CONDITlONS'Co"'lili"""COnlrltu"09 10 lilt ..ath but not """"ting in the u,derlyi1\9 Cause giy"" "' PART I.
<br />
<br />1~..wA5 MEDICAL ElCAMINER'
<br />OR CQRONERCONTACTED?
<br />~ YES 0 NO
<br />
<br />! ~l. ~NNER OF DEATIi. . 21b.IFTAANSPORTATION INJtJllV 21e. WAS AN AUTOPSY PERFOIlMEO'I
<br />I II ,-, ~,....... (J Driver~r I
<br />a Ncn plell".n\loitllin pasl r..' : . · UI .... ~"..- ........,.- I a YES :5" NO
<br />
<br />: .0 PregnlOlll'''. o. delll> 0 AcciOen.O PencIng __gat"" a passoroge,. .
<br />:J Pode.,.,an j I
<br />Q No! p,ego'lII. IIIiI ~"",""nl W~~"' 42 dlrs 0' dlllll a ilUiddI :1 CPUld not ~.Wlennlned ! 2111 WEllE AUlOPSY FINDINGS AVAlL4BLE TO
<br />::JOIhe,tSpecly" ~
<br />1;;1 Noipregtant tluI Pf'9I\lInI oI;j dqs 10 I y....llllo.. dNlll ' I OOMI'I.ETE CAUSE OF DEATH?
<br />
<br />o Unk""",ndP;og""nIWill1inll>Bp...tyoa. I' '. ; ~ 1 a VES__~~~-
<br />
<br />22a. DATE OF INJURY (Uo.. O,V. Y'.) ! 22b. TIUE OF INJURY [22.. PUCE OF INJURY.AI hom.. fann. Slt'HI. f,.IOry. gfflce blriJdmg. eonstru<:,,,,,, SIlO. 01. (Spee'tyl I
<br />
<br />. ': t,-- , - ..-- -,-"'--j-.'--~ . .-!
<br />
<br />
<br />~::::~::~:::..__u =- _______ _ .,,~ I
<br />~II' !,:::'::::::~M:..~:~:r:r.) 2~TIMEOFDEATH 1III f;~~!:::.".); :!:~::. m
<br />
<br />Ii! .' m : ~I,ji 1 April 7. 2006 . 10: 16 am m
<br />f 23d. 10 IIl8 bt5101lOy knololldgl. dlatll oo:uR.d Ilill. ~me. dll. and p1ac. II 240. On thI bl5l5 ole
<br />= .nddueIOII'lOClIus'I'I,lal.d. (llill"IIU'UndTrtl'I" : ~ ~ l""I'm..di~'
<br />
<br />
<br />25. DIOTOB4CCO USE CONmI8UTE 10lHE DEATH? i Ua. H"'S DRG...N OATlSSUE DON~TI01\l BEEN CONSIDERED?
<br />I
<br />::J YES ':l NO (] PllDB481.V ~ UNKNOWN !. 0 YES' ~NO
<br />2T. NAIIE. IffiE AND ADDRESS OF CEFmFIER (PliYSICI...N. CDRONEIl'S PliYSIClANQR COUNTY ATTORNEY) (Type or Pri.11
<br />Mark J. Young, Hall County Attorney..231 S N~
<br />
<br />
<br />
<br />~APR J 6 2006
<br />
|