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<br />STATE OF NEBRASKA
<br />
<br />,
<br />WHEN THIS COpy CARRIES THE RAISED.5EAL OF THE NEBRASKA DEPARTMENT OF HEA4TJi-AJViV(Ul1AN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH THE N. EBAASKA\ ~ffARt"'." E1N.. ...r OF HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FCJ~ ,\(1,'75ll~ 'R'Ett;j/ir1iS..,.."i;
<br />.~. ,,' .." , ",::l.:.'r{2..'L~_
<br />DATE OF ISSUANCE l~i " '. .,1 i.f{~~
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FltlA"NS'ArilO'SU~PON8"'\ 3' 19 0 0
<br />CERTIFICATE OF DEATH ~" " ,'II: " U .
<br />~ -~,
<br />
<br />oEe 0 3 2008
<br />
<br />200902639
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />
<br />1. DECEDENT'S.NAME (Firsl,
<br />Bernard
<br />
<br />Middle,
<br />Leo
<br />
<br />Last,
<br />McGahan
<br />
<br />Suflix)
<br />
<br />2_SEX
<br />Male
<br />
<br />3 DATE OF DEATH (Mo.. Day, Yr.)
<br />November 15, 2008
<br />
<br />6. DATE OF BIRTH (Mo_, Dey, Yr,)
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a, AGE'~a.1 Birthday 5b. UNDER 1 YEAR
<br />(Yrs,) MOS, DAYS
<br />80
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />Elsie, Nebraska
<br />
<br />August 20, 1928
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />507-30-5236
<br />
<br />8a. PLACE OF DEATH
<br />1::lQ.SflIAL: I:l Inpatient
<br />
<br />0lliEB: I:l Nursing Home/LTC I:l Hospice Facility
<br />
<br />8b. FACILITY.NAME (II not Instllutlon, give streel and numbar)
<br />
<br />- - QI ERlOutpalienl
<br />
<br />I:l Decedant'. Home
<br />
<br />St. Francis Medical Center
<br />
<br />Clooo.
<br />
<br />Cl Other (Specify)
<br />
<br />8c. CITY OR TOWN OF DEATH (InClude Zip Code)
<br />Grand Island
<br />
<br />9a_ RESIDENCE.STATE
<br />
<br />Nebraska
<br />
<br />68803
<br />
<br />8d, COUNTY OF DEATH
<br />Hall
<br />
<br />9b, COUNTY
<br />Hall
<br />
<br />
<br />68803
<br />
<br />9d. STREET ANO NUMBER
<br />411 W. 17th
<br />
<br />9f. ZIP CODE
<br />
<br />9g_ INSID!: CITY LIMITS
<br />gl YES I:l NO
<br />
<br />lOa. MARITAL STATUS ATTIME OF D!:ATH ell Merrled I:J Never Married
<br />
<br />lOb, NAME OF SPOUSE (Firsl, Middle, Last, Suffix) It wife, give maiden name.
<br />
<br />I:l Marr'ed, bul .eparaled I:l Widowed Cl Divorced Cl Unknown
<br />
<br />Carol Ann Asher
<br />
<br />11. FATHER'S.NAME (Flrsl, Middle,
<br />Matthew
<br />
<br />13, EVER IN U,S, ARMED FORCES? Give detee of .ervicell ye..
<br />(t.r,~,:0,,~~27 /1946 1/13/1952
<br />
<br />15, METHOD OF DISPOSITION
<br />
<br />Q[Burial Cl Donation
<br />
<br />I:J Cramatlon I:l Entombmenl
<br />
<br />I:l Ramoval I:l Other (Specify)
<br />
<br />Lasl,
<br />McGahan
<br />
<br />Sultix)
<br />
<br />12, MOTHER'S.NAME (First,
<br />
<br />Lena
<br />
<br />Middle, Maiden Surname)
<br />
<br />Lindauer
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />
<br />Ann McGahan
<br />
<br />lBb_ LICENSE NO_
<br />RYO
<br />
<br />I Be. DATE (Mo_, Day, Yr. )
<br />November 20, 2008
<br />
<br />STATE
<br />
<br />CITY /TOWN
<br />
<br />Grand Island Cemetery,
<br />
<br />Grand Island, NE
<br />
<br />
<br />Grand Island NE.
<br />
<br />PART I. Enter the chAIn (')t p.ven1.~--diseases, injuries, Or complications-~that directly cauSed the death. DO NOT enter termlflal events such as ca.rdlac arrest,
<br />respiratory arresl, or ventricular fibrillation withoul showing the etiology_ DO NOT ABBREVIATE, Enler only one causs on a line, Add sddltionallines if neceseary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />on.et to death
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl..... or condlUon resulllng
<br />In death)
<br />
<br />(a) cardiac arrest
<br />DUE TO, OR AS A CONS!:QUENC!: OF:
<br />
<br />: immediate
<br />I onsello dealh
<br />I
<br />I
<br />lunknown
<br />I on.ello death
<br />
<br />Sequenllally 1111 condlllonl,lt
<br />Iny, leading \0 the CIIuleneted
<br />on tin...
<br />Enter1he UNDERLYING CAUSE
<br />(dll.... Or Injury that Inltlalod
<br />Ihe event. reeulUngln dealh)
<br />LAS!'
<br />
<br />~) coronary artery disease
<br />DUE TO, OR AS A CONSEQUENC!: OF:
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset 10 death
<br />
<br />(d)
<br />PART iI_ OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but nol resulting in the underlying cau.e givan in PART I.
<br />
<br />19_ WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />Cl YES Xl NO
<br />
<br />20. IF FEMALE:
<br />
<br />21 a, MANNER OF DEATH
<br />)0 Nalural I:J Homicide
<br />
<br />I:J Accidenll:l Pending Investlgetlon
<br />
<br />21 b.IF TRANSPORTATION INJURY
<br />Cl Drlver/Operalor
<br />
<br />I:l Passenger
<br />
<br />I:l Peda.trian
<br />
<br />I:l Other (Specify)
<br />
<br />21d, WEAE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />Cl VES II NO
<br />
<br />21.. WAS AN AUTOPSY PERFORM!:D?
<br />
<br />I:l Not pregnant within past year
<br />I:J Pregnanl st time of desth
<br />I:l NOI pregnanl, bUI pregnant within 42 days of dealh
<br />I:J Not pregnant, but pregnanl43 days 10 1 year before death
<br />o Unknown if pregnBnl within the past year
<br />-. -LIM~ er ItI.:tlR:
<br />
<br />
<br />22a. DESCRIBE HOW INJURY OCCURRED
<br />
<br />aNO
<br />
<br />I:J YES
<br />
<br />I:J Suicide I:J Could not be delermlned
<br />
<br />. ~J.U:fW' At h<,.,,~::h.I..., .c.l, a4t, rac.ory."Otftce bl.li,iJil'Y, I.iUII~~ll.II.iUUn lilltl, IfC:lSpTClTyl-
<br />
<br />22d, INJURY AT WORK?
<br />
<br />I:l YES I:l NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a, DATE OF D!:ATH (Mo" Day, Yr_)
<br />
<br />
<br />ne
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b_ TIM!: OF D!:ATH
<br />
<br />
<br />m
<br />
<br />23b. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />230. TIM!: OF DEATH
<br />
<br />24c, PRONOUNCED DEAD (Mo" Day, Yr,) 24d, TIM!: PRONOUNCED DEAD
<br />m
<br />
<br />m
<br />
<br />23d. To the besl of my knowledge, death occurred al the time, date and piece
<br />and due to Iha eau.e(s) .Iated, (Signature and Tltte) "
<br />
<br />25. DID TOBACCO USE CONTRIBUT!: TO THE DEATH?
<br />
<br />260_ HAS ORGAN OR TISSUE DONATION BE N CONSIDERED?
<br />
<br />26
<br />
<br />I:J YES 12!1 NO I:J PROBABLY I:J UNKNOWN I:J YES Xl NO Nol Applicable il26a is NO I:J YES I:J NO
<br />27, NAME, TITLE AND ADDRESS OF C!:RTIFIER (pHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />
<br />Gail VerMaas, Deputy Hall County Attorney, 231 S Locust Street, Grand Island, NE 68801
<br />
<br />28e. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo" Day, Yr,)
<br />
<br />
<br />DEe
<br />
<br />1 2008
<br />
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