|
<br />STATE OF NEBRASKA
<br />
<br />.
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANR.I:i..lJf:16.(:J.SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKIj~191!f~f?H1EtJT'bf'...t'E.AL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VlIA~ ~~P'1\ ...:~ .>' II
<br />~.., ....~:LTI7~.:.(~,.;.
<br />DATE OF ISSUANCE .' '.'::'.:. ......;;6.~. . .....:...... ii',
<br />'l"t... .... '" " .
<br />sTANt~y S. COOPEIt"... ...................... ,', .... '
<br />ASS. IS..T~N. T~... ..~1!1'......~ . ..'GiS...t.R.....A......fl.~.....:.: ::
<br />DE~A'tfn:1E~J-1EAL 1fttANfiJ:';~ :-
<br />HUMIIift Sti~lr;Efi,., ",." : (:; ,.'
<br />\_'.;::~~., . _. .1"/~v. :F;~',.~:~','.' _ :;.':'.~:~>\~ .:_. .: ~;,' ~:'~'~,.
<br />, ." c," ..~.SHr.:::',-~i.' ,,$",:,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND sup~6;.tit~.; .',';;.' 3..'....5".'. ~ ~
<br />_ CERTIFICATE OF DEATH _ ' ':l:J :J;'lc..:', () l
<br />
<br />APR 2 8'2009
<br />
<br />~
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />'200903814
<br />
<br />..~
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />1. DECEDENT'S.NAME (Firsl,
<br />Irene
<br />
<br />Mlddlo,
<br />Viola
<br />
<br />Last,
<br />Feaster
<br />
<br />Suffix)
<br />
<br />2. SEX
<br />Female
<br />
<br />"
<br />3. DATE OF DEATH (Mo" Day. Yr.)
<br />April 16. 2009
<br />
<br />93
<br />
<br />
<br />6. DATE OF BIRTH (Mo" Day, YL)
<br />
<br />Gresham. Nebraska
<br />
<br />50. AGE.la.t Birthday
<br />(Y".)
<br />
<br />July 3. 1915
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />506-03-3308
<br />
<br />eo, PLACE OF DEATH
<br />1iOSf.lIAL: Q Inpatient
<br />
<br />QMB: II Nursing Homo/lTC Q Hospice Fecillty
<br />
<br />6b. FACiliTY-NAME (If not inotllullon, give .treet and number)
<br />
<br />Q ER/Outp2.tiant Q Decedent's Home
<br />
<br />Tiffany Square Care Center
<br />
<br />60. CITY OR TOWN OF DEATH (Inoludo Zip Code)
<br />Grand Island
<br />
<br />68803
<br />
<br />Q OCY\ Q Other (SpeCify)
<br />
<br />ed. COUNTY OF DEATH
<br />Hall
<br />
<br />.a. RESIDENCE.STATE
<br />Nebraska
<br />
<br />Qd. STREET AND NUMBER
<br />1819 W. Division
<br />
<br />9b. COUNTY
<br />Hall
<br />
<br />
<br />Qt. ZIP CODE
<br />68803
<br />
<br />9g.INSIDE CITY LIMITS
<br />Xl YES Q NO
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH Q Marrlod 0 Ne.er Married t Ob. NAME OF SPOUSE (First, Mlddla, Lost, Suffix) It wilo, gl.o maiden name.
<br />
<br />Q Marriod, but .eparated IJ[Wldowod Q Di.orced Q Unknown
<br />
<br />11. FATHER'S.NAME (Firsl,
<br />Clarence
<br />
<br />Middle,
<br />L.
<br />
<br />Lasl,
<br />Thompson
<br />
<br />Sulfix)
<br />
<br />12. MOTHER'S-NAME (First,
<br />Anna
<br />
<br />Middla,
<br />
<br />Maiden Surname)
<br />Lindquist
<br />
<br />14b. RELATiONSHIP TO DECEDENT
<br />Daughter
<br />
<br />160. DATE (Mo., Day, Yr.)
<br />April 20. 2009
<br />
<br />13. EVER IN U.S. ARMED FORCES? Gi.e dato, ot ,er.loell ye.. 14a.INFORMANT-NAME
<br />(Yoo, no, or Unk.) No Sue Wilcoxson
<br />
<br />15. METHOD OF DISPOSITION
<br />~ Burial Q Donation
<br />Q Cremation Q Entombment
<br />Q Romo.al Q Other (Speoily)
<br />
<br />16a. BALMER'SIGNAT~.
<br />
<br />~ rJ,. 1\JJ"f)
<br />
<br />16d. CEMETE Y. CREMATORY OR OTHER lOCATION
<br />
<br />1 eb, liCENSE NO.
<br />
<br />328
<br />
<br />CITY I TOWN
<br />
<br />STATE
<br />
<br />Greenwood Cemetery.
<br />
<br />York. Nebraska
<br />
<br />17a. FUNERAL HOME NAME AND MAiliNG ADDRESS (S"oel, City or Town. Slele)
<br />Apfel Funeral Home. 1123 West Second. Grand Island. NE.
<br />
<br />
<br />
<br />17b. Zip Code
<br />68801
<br />
<br />PART I. Enter the chili" of Itvenls.-dlseases, Injuries, Or CQmpllcatlonsuthat directly ceused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventflcular fibrillation without showing 'he eliology. DO NOT ABBREVIATE, Enter only one cause On a line. Add addItional lines If necessary.
<br />
<br />APPROXIMATE INTERvAL
<br />
<br />IfolMEOIATE CAUSE (Flnal
<br />dl.... or condition re.utting
<br />Inde""')
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />~_A~t/t.Wtl%>
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />4~
<br />
<br />9 j ~,A...s:._
<br />
<br />onset to death
<br />
<br />Sequen.lelly II.. oondlllona. if
<br />any,ieodlng to the .au..lloled
<br />on line a.
<br />Ente<fhe UNDERLYING CAUSE
<br />(dl..... or Injury thai InlflOled
<br />Ihe _ ","unlng In death)
<br />LAS!'
<br />
<br />(b)
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />onset to death
<br />
<br />(0)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS.CondIIlOn. oontrlbuting to tho death but nol ra.ulting in the underlying cau.a given in PART I.
<br />
<br />20. IF FEMALE:
<br />~ot pregnant within past year
<br />Q Pregnant alllmo ot death
<br />Q Nol pregnant, but pregnant within 42 dayo of death
<br />Q Not pregnant, but pregnant 43 days to 1 year before death
<br />CI 'Unknown if pregnant within the pa.st year
<br />
<br />21a, MANNER OF DEATH
<br />~tural 0 Homicide
<br />
<br />o AccidentCl Pending Investigation
<br />
<br />o SuiCide 0 Could not be determined
<br />
<br />2t b.IF TRANSPORTATION INJURY
<br />Q Drivor/Operator
<br />
<br />o Passenger
<br />
<br />Q Pedestrian
<br />
<br />Q Other (Spoollyl
<br />
<br />19. WAS MEDiCAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />Q YES fL,tJO
<br />
<br />21c, WAS AN AUTOPSY PERFORMED?
<br />
<br />Q YES )If NO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />Q YES )(NO
<br />
<br />220, DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY-At horne, farm, $treel, factory, office building. construcllon sUe, etc. (SpeCify)
<br />m
<br />
<br />J 220 DESCRIBE HOW 1t:!,l,U1'!Y. QregU8BEO
<br />
<br />
<br />Cl YES Q NO
<br />
<br />
<br />22f.lOCATION OF INJURY. STREET & NUMBER, APT NO. CITYITOWN
<br />
<br />SWO
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo.. Day, Yr,)
<br />"/- , ~. (J 9
<br />
<br />23b. DATE SIGNED (Mo" Day, ~
<br />-t.. 1"'07
<br />
<br />23d. To the be~~nOWledgel death OCcurred al the lime, date and place
<br />and duo 0U..(5):ta -({nOCllle) ~
<br />
<br />24a. DATE SIGNED (Mo.. Day, Yr,)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />.J~
<br />"'1A~
<br />h5~
<br />E.tn ~ Z
<br />8ffizO
<br />1l~5
<br />~a:u
<br />811
<br />
<br />m
<br />
<br />23c. TIME OF DEATH
<br />0035
<br />
<br />24c, PRONOUNCED OEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />248. On the basis of examination and/or investigation, In my opinion death occurred at
<br />the limo, date and plaoo and due to the cau.e(.) .tatod. (Slgnaluro and Tille) ,.
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />26.. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />Not Appllcabla il 26a is NO_O YES ~NO
<br />
<br />Q YES ~NO Q PROBABLY Q UNKNOWN Q YES NO
<br />27. NAME, nfLEAND ADDRESS OF CEFITIFiER (PHYSICIAN, CORONER'S PHYS'ICIAN OR CQUNTY ATTORNEY) (Type or Prinl)
<br />David Colan M.D. 729 N. Custer Av Grand Island.
<br />
<br />
<br />NE 68803
<br />2Bb. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />APR 2 1 2009
<br />
<br />HHS-6111/03 (55061)
<br />
|