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<br />STATE OF NEBRASKA <br /> <br />'(~I <br /> <br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL TH AND HUMA!y SERVICES, IT CERTIFIES <br />THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPAR.'fM~NT OF HEAL TH AND <br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VI.T:~~!,: .~ .... <br /> <br />DATE OF ISSUANCE .' 'c/ jpt~~,~ <br />200903460 $i ~'f.. .t(JcfpEiif:>:~.'i....-. <br />Assls.TA STATER'EGIST/JAR <br />NOV 2 5 2008 DJ5?P.RTMENT1JF1IEA,.~rf-/.;-AF:-!D <br />LINCOLN, NEBRASKA HUMAN S:E<RVfCE$'~.t:'; ......:.. . ..~ <br /> <br />\.~) .:i-:fff:(.~! " <br /> <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANce AN!'l'~1" ~!'. . ~::.;.l:.,. ~,\, .... <br />Amended NovemE_~r 24. 2008 CERT_IFICATE OF DEATH "J' ,. ". ..' .; <br /> <br />~ <br /> <br />1. SOCIAL SECURITY NUMBER <br />508-14-4205 <br /> <br /> <br />May 31. 1919 <br /> <br /> <br />1. DECEDENT'S.NAME (Flrsl. Elswor~~dlo. ~aSI. <br />Llo d ~8Vp~t&- DeFreece <br />4. CITY AND STATE OR TERRITORY. OR FOR~IGN COUNTRY OF BIRTH 5a. AG~'~ast Blrlhday <br />(Yrs.) <br />Unaddlla, Nebraska 89 <br /> <br />Sulllx) <br /> <br />2. SEX <br />Male <br /> <br />----2..Q.QJi <br /> <br />Ba. PlACE OF OEATH <br /> <br />1:lQSfJIAI.: <br /> <br />Q Inpatienl <br /> <br />QJJtil: tlNurslng Homal~TC Q Hospico Facility <br /> <br />8b. FACILITY. NAME (It nol Inslllullon. giva Slrool ond numbor) <br /> <br />Q ERIOutpallenl <br /> <br />o Decedent's Home <br /> <br />Veterans Admin. Center <br /> <br />Sc. CITY OR TOWN OF DEATH (Includo Zip Codo) <br />Grand Island 68803 <br /> <br />Q 0CiI Q Other (Specify) <br />8d. COUNTY OF DEATH <br /> <br />9a. RESIDENC~.STAT~ <br /> <br />9b. COUNTY <br />Hall <br /> <br /> <br />Hall <br /> <br />9d. STREET ANO NUMBER <br /> <br />91. ZIP CODE <br /> <br />9g. INSIDE CITY liMITS <br />C}cYES Q NO <br /> <br />68801 <br />1 Oa. MARITA~ STATUS AT TIM~ OF DEATH IJ{Marrlad Q Nevor Marriod lOb. NAME OF SPOUSE (Flrsl. Middle. last. SUllix) 1\ wife. give maiden name. <br /> <br />Q Divorced Q Unknown Unadean Arms trong <br /> <br />leSl, <br /> <br />SUlllx) <br /> <br />12. MOTHER'S-NAME (First. <br /> <br />Alma <br /> <br />Middle. <br /> <br />Maiden Surname) <br /> <br />CITY (TOWN <br /> <br />McNair <br />14b. RELATIONSHIP TO DECEDENT <br />Dau hter <br />I Be. DATE (Mo.. D.y. Yr. ) <br />e tember 23 2008 <br />STATE <br /> <br />13. EVER IN U.S. ARMED FORCES? Give d.l.s olsorvico if yos. 14a. INFORMANT-NAME <br />(~:..~o:o,unk.)Army 06/161 1941-:!01 1 11945 L <br />lS.. EMBAlMER.SIGNATURE <br /> <br />Q Oonatlon <br />XI Cromallon Q Enlombmonl <br />Q R.mo".1 Q Olhor (Spoclfy) <br /> <br />Not Embalmed <br />lBd. CEMETERY. CREMATORY OR OTHER LOCATION <br /> <br /> <br />Westlawn Memorial Park Crematory. Grand Island. NE <br /> <br /> <br /> <br />17.. FUNERAL HOME NAME AND MAiliNG ADDRESS (Str.el, City or Town, Stato) <br />Livingston-Sondermann Funeral Home. 601 N. Webb Rd. Grand Island. NE <br /> <br />PART I. Enter the chain lIf RVRnt~..dlseases, Injuries, or compllclltlonanthat directly caused the death. DO NOT entetterminalevenrs such as cardiae arrest, <br />respiratory arrest Or ventricular fibrillation without showing Ihe etiOlogy. 00 NOT ABBREVIATE. Enter only one cause on B lins. Add addlUonslllnes If nec.ssary. <br /> <br />APPROXIMATE INTERVAL <br /> <br />IMMEDIATE CAUSE. <br /> <br />on.ello d.olh <br /> <br />IMMEOfATE CAUSE (FInal <br />dl.....orcondlllon reoulting <br />In death) <br /> <br />(.) Cardio pulmonary arrest <br />DU~ TO. OR AS A CONSEQUENCE OF: <br /> <br />onoollo d.ath <br /> <br />Sequtntl.lly lI.t conditions, II <br />any, leedlng 10 tho .....11_ <br />on Une I. <br />E_the UNDERLYING CAUSE <br />(dl_ or Injury thollnlUoted <br />the e_ multing In death) <br />l.A5I' <br /> <br />(b) Sepsis syndrome <br />DU~ TO, OR AS A CONSEQUENCE OF: <br />(c) Pneumonia <br />OU~ TO. OR AS A CONSEOUENCE OF: <br /> <br />onset to death <br /> <br />onset 10 death <br /> <br />(d) Dysphagia <br />1 B. PART II. OTHER SIGNIFICANT CONDlTlONS.Condilions conlrlbullng 10 the dealh bul not resulllng In Ihe underlying cau.o givon In PART I. <br /> <br />20. IF F~MAlE: <br />o Not pregnant within past year <br />Q pr.gnanlat limo 01 doath <br />Q Nol pregn.nt. but pregnant within 42 days 01 doalh <br />o NOI pr.gn.nt. but pregnanl43 day. 10 I yoar bofor. d..,h <br />Q Unknown II pregn.nl within tho p..t ye.r <br /> <br />21a. MANNER OF DEATH <br />~ N.'ural Q Homlcldo <br /> <br />Q Accld.ntQ Pondlng Invostlg.llon <br /> <br />Q Suicide Q Could not bo dOlormined <br /> <br />21b.IFTRANSPORTATION INJURY <br />Q Orl"orlOpOralO' <br /> <br />Q P....ng.r <br /> <br />o Pedestrian <br /> <br />Q Olh.r (Speclly) <br /> <br />19. WAS M~OICAl EXAMINER <br />OR CORONER CONTACTED? <br /> <br />Q YES ]I! NO <br /> <br />21c. WAS AN AUTOPSY PERFORM~D? <br /> <br />Dementia. Parkinson's disease, CVA <br /> <br />Q YES XI NO <br /> <br />21d. WERE AUTOPSY FINDiNGS AVAI~BlE TO <br />COMPLETE CAUSE OF D~TH? <br />Q YES Q NO <br /> <br />22a. DATE OF INJURY (Mo., Day, Yr.) <br /> <br />22b. TIME OF INJURY 22c. PLACE OF INJURY.At homo. farm, "root. lactory, olflc. building, conalrucliOn ailo. etc. (Spoclly) <br />rn <br /> <br />22d.INJURY AT WORK? <br /> <br />CITYITOWN <br /> <br />SlJ\!E <br /> <br />ZIP CODE <br /> <br />24.. DATE SIGNEO (Mo.. Day, Yr.) <br /> <br />24b. TIME OF DEATH <br /> <br />.:23 . 0 <6" <br /> <br />liU <br />b5~ <br />H~i5 <br />llZ~ <br />~iu <br />all <br /> <br />m <br /> <br />24c. PRONOUNCED D~AD (Mo.. Day. Yr.) 24<1. TIME PRONOUNC~O DEAD <br />m <br /> <br />24e. On the ba'sls of examination and/or investlgatlon,in my opinion death occurred at <br />Ih. tlm., dolo and ploc. and duo 10 the caua.(s) statod.(Slgnolur. and Titl.) " <br /> <br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br /> <br />2Bb. WAS CONSENT GRANTED? <br /> <br />Q YES iK- NO Q PROBABLY Q UNKNOWN Q YES NO Nol Appl~.blo 1126. Is NO Q YES NO <br />27. NAME. TITLE AND ADDRESS OF CERTIA'ER'(PHYSICIAN, CORONER'S PHySICIAN OR COUNTY ATTORNEY) (Typo Or Prinl) <br />Heidi Beckett, M.D. Veterans Admin Center 2201 N Broadwell Grand Island, NE 68803 <br /> <br />2B.. REGISTRAR'S SIGNATURE <br /> <br /> <br />2Bb. DATE FILED BY REGISTRAR (Mo.. Day, Yr.) <br /> <br /> <br />HHS-6111/03 (55061) <br />