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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OFH.,~AL~'TH.~AI~HL~7~t21~l.SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEx'B,~ ~ ,1~1'f`bF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FDxP ~~~OR~' ~7 ,::• ` ~ '
<br />~ 4 ,~to ~ rrJ ,
<br />DATE OF ISSUANCE ~ ., }.. ~ ~ ~'~r
<br />39~~ COOPER ~ ~
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<br />i¢S ~'AN ~`TC"rRE~I57~A`Ra '",~
<br />L!'~P7~R~71N~F 1HEALT"H ANA `:~'
<br />LINCOLN, NEBRASKA ~l~-N.~E~VIE'L~S ~~ °~ ' ~
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<br />STATE 4F NEBRASKA-DEPARTMENTOF WEALTH AND HUMAN SERVICES FINANC~tAND sc~r~ta , (:~ ~~
<br />CERTIFICATE OF DEATH e. '. ~
<br /> 1. DECEDENT'S•NAME (Firer, Middle, Lest, Suffix) 2. SEX 3, DATE OF DEATH (Mo.;Day,Yr.)
<br /> Maurice .Tames Morhain Male November 5, 2008
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Last Birthday 5b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. PATE OF BIRTH (Mo., pay, Yr.)
<br /> (Vra.) MOS. DAYS HOURS MIN3.
<br /> Shenandoah, Iowa 74 August 4, 1934
<br /> 7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH ~ """'
<br /> "']08"'g'~=8~b4 ' ~ HOSPITAL: ~] Inpatient 1~ ^ NursingHomelL7C C7 HospiceFacitity
<br /> --917. FAEILITY--NAME (II nor Insfllutioa, plvu. arrest .and numhe7)^.
<br />^ EH/Outpatient ^ OeCedunP; Home ~ ~ ~ -
<br /> St. Francis Medical Center
<br /> ^ D04 OOther(Specity)
<br /> 8c. C17Y OR TpWN OF DEATH (Include Zip Code) Bd. COUNTY OF pEATH
<br /> Grand Island, 68803 Hall
<br /> Ba.RE31DENCE•STATE ~ 96.000NIY 9c. CITY OR TOWN
<br /> Nebraska Hall Grand Island
<br /> 9d.5TREETAND NUMBER ~ 9e. APT. NO 9f. ZIP COpE 9g. INSIpE CITY LIMITS
<br /> 1524 West 4th 65801 ~) Yes ^ No
<br /> 70a. MARITAL STATUS AT TIME OF DEATH [$Married ^ Never Married 10b. NAME pF SPOUSE (First, Middle, Last, Sutflx) If wife, give maiden name.
<br /> ^Marrled,butseparated ^Widowed ^Divorced ^Unknown Sharon Poole
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<br /> 11. FATHER'5•NAME (First, Mlddle, v~Last, Suffix) Middle, Maiden Surname)
<br />12. MOTHER'S•NAME (First,
<br /> Elmer Morhain 0 al _ Watson
<br /> 13. EVER IN U.S. ARMED FORCES? Give dates of service If yes. 14a. INFORMANT•NAME~- 14b. RELATIONSHIP TO pECEDENT
<br />~;' (ves,nc,orunk.) NO Sharon Morhain Wife
<br />;~ ~..~.
<br />15. METHOD pF DISPOSITION - 18a. EMB LMER•SIGNA7UR 166. LICENSE N0. 16c. DATE (MO., Day, Yc )
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<br />. November 8 2008
<br />[~8urial ^ Donation ~~ t ~ a
<br />~.~.~.u ^Gremation ^Entdm6ment 16d.CEMETERY,GiEMATORYOROT LOCATION CITY/TOWN STATE
<br /> Q Removal ^Omer (spaddy)
<br /> Grand Island Cemetery, Grand Island, Nebraska
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<br /> SS (Street,CltyorTawn,State) 176.ZIpCode
<br />17a. FUNERAL HOME NAME ANp MAILING ADORE ~ ~ - ~
<br /> A fel Funeral Home 1123 West Second Grand Island, NE 68801
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<br /> 18. PART I, Enter the Chain of events••diseases, injuries, Or cdmpGcatiwts--mat dxect'y caused the death. p0 NOT Bnter terminal events such 85 cardiac arrest, I APPROXIMATE INTERVAL
<br /> respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add addltlonal lineslf necessary. i -. - -._ ...
<br /> IMMEDIATE CAUSE: ~ onset to death
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<br />6:~' dlsesaeorcondhlonreaulting pUE TO,OR AS A C NSEOUENCE OP: I onset to death
<br />~ In death) ^'r".'_.` , _ ri
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<br />Sequentlpllyllateonditlona,lf (b) r I
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<br /> any,leadingtotheceuaellatad DUETO,ORASACONSEO
<br />UENCEOR i onset tad th
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<br />EmartheUNDERLYINGCAU5E t/' ~ ~ / • ~~
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<br /> (dlseaeeorlnJurythatlnldated (c) ~~'"~~,~( ~
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<br />:':~ thaeventareaullinglndeath) pUET0,0 5ACONSEOUENCEOF: ~w^^ ~` nn ~~ tl onset to death
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<br />19. PART IL OTHER SIGNIFICANT CONDITIONS•Conditions contributing to the death but not resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br />~7," pR CORONER CONTACTED?
<br />,,,~`~t ^ YE3 ND
<br /> -2o.IFFEMALE: 21a.MANNEROFDEATH ~ 21 b.IFTRANSPORTATIONINJURY 21 c. WAS AN AUTOPSYPERFpRMED7
<br />TM ^ Nol pregnant within past year .Natural ©Homlclda ^ Driver/Operator
<br />©YES ~NO
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<br />• ^Paesenger
<br />[„) pregnant at time or death ^ Accldent^ Pending Investlgatlon
<br />
<br />n Q Not pregnant, but pregnant within 42 days of death ^ Pedestrian 21 d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />^ Suicide ^ Ceuld not be determined
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<br />~ ^ Other (Specify)
<br />^ Not pregnant, but pregnant 43 days to 1 year before death COMPLETE CAUSE OF DEATH7
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<br />5, ^Unknown t pregnant within the past year ~,.._.__•,_.,~ ^YES ~VO
<br /> -22a. c~.'«-E :.~T,.LRY !k~e -nav Yr,l 22b. TIME OF INJURY ~ 22c. PLACE pF INJURY•At home, term, stredt, factory, office building, construction alts, etc. (Specify)
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<br />' 22d.INJURYATWORK7 22e. DESCRIBE HOW INJURY OCCURREp - •
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<br />(] YES ^ NO
<br />' ~ 221. LOCATION OF INJURY • STREET & NUMBER, APT. NO. CITYROWN ~ STATE ZIPCOpE
<br /> 23a. DATE OF DEATW (Mo., Day, Yr.) ~~ x ~, T 24a. BATE SIGNED (Mo., Day, Yc) 24b.TIME OF DEATH
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<br />i ~~ 23b.0ATESIGNEp(MO.,Day,Yr.) 23c.TIMEOFDEATH $_~ 24c.PRONOUNCEDDEAp(Mo.,Day,Yr.) 24d.TIMEPRONOUNCEDDEAD
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<br />Paz Q 11:55 Am E
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<br />$ ° O 23d. Te the best of my knowledge, death occurred al the time, data and place '+ w ~ G 24e. On the basis of examination ahdlor investigation, in my opinion death occurred at
<br />p the lime, date and place and due to the cause(s) stated. (Signature and Title) 'I
<br />and due ause(s) sled. (Signature and Title) • o
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<br />~ 25. DIp708A000 USE NTR UTETDTWE DEATW7 28a. HAS ORGAN OR TISSUE pONATION BEEN CON5l0ERE0? 266. WAS CONSENT GRANTED?
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<br />\ ^YES Tj~'`'~'~0 PROBABLY _ ^ UNKNOWN ^YES ~I NO Not Applicable if 28a le ND ^YES ^_ NO
<br />. 27.NAME,TITLE•ANDAODRESSOFCERTIFIER (P~YSICIAN,CORONER'SPHY5ICIAN OR COUNTY ATTORNEY) (Type orPrlnt)
<br /> Jana G. Van Wie M.D. 2444 West Faidle Ave. Grand Island NE 68803
<br /> 28e. REGISTRAR'S SIGNATURE SY REpISTRAR (Mo., pay, Yr.)
<br />28b. PATE FILEp
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<br />l•ou ~ 0 2008
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