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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL~~"7a11~ 9~IrJ~1Al1FSERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBiZ~~Q1.IBL~I~~N~ OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL pEPOSITORY FOR~1~1`k11• 0~.~;
<br />DATE OF ISSUANCE. ",; ,~~~~~~'° ~~
<br />~CT ~ 7 ZOOS "ST.AN S.,C O~~'R •: '.. ;
<br />2 0 0 ~- 0 4 4 2 s ~~~A~~~~ ~~~ ;~~~a
<br />LINCOLN, NEBRASKA 1bi!lJA1Aly SERVI~'~S„ ,: t;' .
<br />STATE QFNEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICES FINAN~~ AIVrD•SUPPb,~ p
<br />CERTIFICATE OF DEATH '' •'--'-~'""~ O 3 0 3 6 8
<br /> 1 DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yc)
<br /> Gerald _.7_ames Barnes le ctober`;9, 2008
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF 81RTH 5a. AOE•Last Birthday 5b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br /> Greeley, Nebraska 83 une 7, 1925
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 541-30-14_8_9
<br />- )J.QSPITAL: ^ Inpatient 41t~ ~[]~NursingHOme/LTC ^HospiceFaclllty
<br /> 8b. FACILITY•NAME (It not Institution
<br />, give street and number)
<br />^ ER10utpatient ^ Decedent's Homa
<br /> Veterans Admin. Medical Center ^ pa+ ^ other(spe~dy)
<br /> ec. CITY Oq TOWN OF pEATH pnclude Zip Code) Bd. COUNTY DF DEATH
<br />~' Grand Island 6$803 Hall
<br /> 8a. RESIDENCE-STATE eb. COUNTY 8c. CITY OR TOWN
<br /> Nebraska __ _
<br />~ ~ Hall Grand Island
<br />
<br />8d. STREETANDNUMBER __
<br />96. APT. NO Bf. Zlp CODE
<br />8g. INBIpE CITY LIMITS
<br /> 907 West ,john _ ~ ,_ 68801 X~J YES ^ ND
<br /> 1oa. MARITAL STATUS AT TIME DF DEATH xE] Married ^ Never Married tOb. NAME OF SPOUSE (First, Mitldle, Last, Suffix) If wife, glue maiden name.
<br /> ']Married, but separated QWidowed Cl pivorced ^Unknown ~ LuEtta French
<br /> 11. FATHER'S•NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Maitlen Surname)
<br />` r~ Ellis Barnes Mar3.e . Mc uire
<br /> 13. EVER IN U.S. ARMED FORCES? Give dates of service If yes. 14a.INFORMANT-NAME 14b. RELATIONSHIP TQ DECEDENT
<br />-;y-i (~jljs,no,orunk.)NaV 3/08/1944-03/30 1945 LuEtta Barnes Wife
<br />~~'r,r 15. METHOD OF DISPOSITION 16a. EMBALMER•SIGNAtuRE ~' 186. LICENSE NO. 18c. DATE (Mo., Dey, Yr. )
<br />~~' ^Burial ^oonation Nvt Embalmed ---- October 10, 2008
<br />-;', ~;• L~Cremation ^ Entombment 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> ^ Removal Q Other (Specify)
<br /> Westlawn Memorial Park Crematory Grand Island
<br />NE
<br /> ,
<br /> 17e. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City orTOwn, State) 17b. Tip Code
<br /> A fel Funeral Home 1123 West Second G 68801
<br />;,.a
<br />
<br />~r , ; 18. PART I. Enter the gheln of events--dlseesea, Injuries, or complications--that directly caused iha death. DO NOT enter terminal events such ae cardiac arrest, I APPROXIMATE
<br /> INTERVAL
<br />'
<br />ii respiratory arrest, or ventricular fibrillation without ahowing the etiology. DD NDT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. I
<br />
<br />
<br />~ IMMEDIATE CAUSE: I onset to death
<br />I
<br />.c~. IMMEDIATE CAUSE (Final ~(a) CardiO pulmonary collapse I
<br /> dlaauaorconditlannaultlra~ pUE 70, OR AS A CONSEQUENCE OF: I onset to death
<br />
<br />' In death)
<br />I 12:42
<br />:~, ,
<br />'
<br />~,t Sequantisllyliatconditions,if m) Lower gastro intestinal
<br />bleed ~ 10/08/2008
<br /> „_.
<br />any, leading to thecaueelleted
<br />DUE T0, OR AS A CONSEQUENCE OF: I onset td death
<br />,f:
<br />~ onlinae.
<br />I
<br />!
<br />~`:f EntertheUNDERLYINGCAUSE
<br />- (diseeseorin(urythatinitiated (0)Anem3.a of chrvn~.c/acute disease
<br /> theevenuresultlnglndeath) pUE TO, ORASACONSEQUENCEOF: I onset to death
<br /> LAST
<br />,lrv~'
<br />' (d)Exacerbation heart failure e'ection fraction 25-30R'
<br />.
<br />r.
<br />-. ,~ 5
<br />18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given in PAR71.
<br />18. WA5 MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br />,;;~:;, Avrtic valve stenosis/insufficient ^ YES ~NO
<br />':~~ 20. IF FEMALE: 21 a. MANNER OF DEATH 216. IF TRANSPORTATIONINJURY 21c.WA5ANAUTOPSYpEflpOflMED7
<br /> [~ No[ pregnant within pact year ~atural ^ Homicide ^ Driver/operator Yy,,yy
<br />•'
<br />^
<br /> ^ pregnant at time of death ^ ACCidenlQ Pending Investigaticn
<br />^Passenger
<br />YE3
<br />~NO
<br />
<br />'~ ^ Not pregnant, but pregnant within 42 days of death
<br />^ Suicide ^ Could not be determined ^ Petlesirian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />~., ^ Not pregnant, but pregnant 43 days ttl 1 year before death ^ Other (Specify) COMPLETE CAUSE pF OEATH7
<br />~;, ^Unknown if pregnant within the past year ~~~ ^ YES ^ NO
<br /> 22a. DATE OF INJURY (Mo., pay, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />;'~ ," m
<br />
<br /> 22d. INJURY AT W
<br />ORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br /> y
<br />^ YES ~} NO
<br /> 22f. LOCATION OF INJURY • STREET & NUMBER, APT. NO. CfTY/TOWN STATE ZIP CODE
<br /> 23a. DATE OF pEATH (Mo., Oay, Yr.) a 24a. DATE SIONEO (Mo., Day,Yr.) 24p.TIME OF DEATH
<br />
<br />~ ~'~ October 09, 2008 a ~_ ~ m
<br /> ~
<br />, yy 23b.DATESIONED(Mo.,Day,Yr.) 23c.TiMEOFDEATH ~'~~ 24c.PRpNOUNCEbOEAD(Mp.,Oay,Yr.) 24d.TIMEPRONOUNCEDDEAD
<br />,: E ~ z October 09 2008 0225 m ~ ° ~ ~ m
<br /> $ b 0
<br />~ 23d. To the best of my kn wtedga,.deAth occurred at the time, date and place
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<br />t ~ ~ 24e. On the baste of exeminatlon and/ar Investigetlon, in my opinion death occurred at
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<br />due tc the cause(s) stated. (Signature and Title) r
<br /> _
<br /> US
<br /> 28. DIDT08A000 USE'CONTRIBUTETOTHE DEATH? 26e. HAS QRGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br /> ^ YES ~l NO ^ PROBABLY ^ UNKNOWN ^ YES L~NO Not Applicable If 28a Is NO ^ YES ~] NO
<br /> 27.NAME,TITLEANDADORESSOFCERTIFIER (PHYSICIAN,CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) __._._
<br />', Fred Echternacht M.D. Veterans Admin. Medic 1 Center 2201 N Broadwell Grand Island N
<br /> 28e. REGISTRAR'S SIGNATURE f 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> u• QCT ~. 5 2008
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