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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES .THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR `VI11AL RFCJJORDS.
<br />DATE OF ISSUANCE
<br />AN
<br />200005057 y5"fL C'.0
<br />S1'S
<br />04/30/2009 i A$ZANT SrATL- h�C rSTRAR
<br />A. T AND
<br />LINCOLN, NEBRASKA c, W I �If I�.SOR'V. ; d
<br />STATE OF NEBRASKA» bEPARTMENT OF HEALTH AND 6UMAN SERVICES ^. 0900889
<br />CERTIFICATE OF DEATH`',''. 2
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix) if.�
<br />7. 011, ice, 1 . • '
<br />\3*DATE OF DEATH (Mo., Day, Yr.)
<br />Raymond Joseph McCarty
<br />Male, • • °'' J!
<br />Aril 23, 2009
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Sa. AGE - Last Birthday
<br />b. UNDER 1 YEAR
<br />Sc, UNIIER'•1,DAY -
<br />.8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs.)
<br />MOS.
<br />DAYS
<br />HOURS....1NIN8.
<br />Merna, Nebraska
<br />80
<br />November 30, 1928
<br />7, SOCIAL SECURITY NUMBER
<br />Sa. PLACE OF DEATH
<br />535 -28 -0429
<br />HOSPITAL ❑ Inpatient OT_HEB ® Nursing Home /LTC ❑ Hospice Facility
<br />❑ ER/Outpatlant ❑ Decedent's Home
<br />8b. FACILITY -NAME (if net Institution, give street and number)
<br />t-
<br />U
<br />Grand island Veterans Home
<br />© DOA other (Specify)
<br />w
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />8d. COUNTY OF DEATH
<br />o
<br />Grand Island 68803
<br />Hall
<br />9a. RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY OR TOWN
<br />w
<br />z
<br />Nebraska
<br />Hall
<br />Grand Island
<br />:D
<br />9d. STREET AND NUMBER
<br />99. APT. NO.
<br />9f, ZIP CODE
<br />9g. INSIDE CITY LIMITS
<br />1720 N. Park AV
<br />1 I
<br />68803
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />!t
<br />d
<br />❑ Married, but separated ❑ Widowed []Divorced ❑ Unknown
<br />May M SChirkofsk
<br />11, FATHER'S -NAME (First, Middle, Last, Suffix)
<br />12, MOTHER'S -NAME (First, Middle, Malden Surname)
<br />33FF"
<br />John A McCarty I
<br />Adelia Rayles
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes.
<br />14a. INFORMANT -NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />(Yes, No, or Unk.) Yes 02/20/1952- 06/20/1954 1
<br />Ma M MCCa
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />18a. EMBALMER-SIGNATURE 18b.
<br />LICENSE NO.
<br />18c. DATE (Mo., Day, Yr.)
<br />C
<br />�
<br />® Burial ❑ Donation
<br />Patricia R. Curren
<br />1092
<br />April 27, 2009
<br />[]Cremation ❑ Entombment
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Specify)
<br />Dale Valley Catholic Cemetery Merna Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />17b. Zip Cade
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />68801
<br />n examples)
<br />CAUSE-OF DEATH ee ns ruct ors -and-
<br />IS. PART 1. enter the chpin of events. - diseases. injuries, or compncatlons4hat directly "used the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE: ; onset to death
<br />IMMEDIATE CAUSE (Final a) Pneumonia ; 1 Week
<br />disease or condition moulting
<br />in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Sequentially list conditions. If b) Dysphagia n 1 Year
<br />any, leading to the cause listed
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE G) Dementia, Vascular a 1 Year
<br />(disease or Injury that Initiated
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />LAST d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given In PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />Coronary Artery Disease
<br />OR CORONER CONTACTED?
<br />1
<br />0:
<br />❑ YES ® NO
<br />U.1
<br />20. IF FEMALE:
<br />21a, MANNER OF DEATH
<br />21b, IF TRANSPORTATION INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />© Not pregnant within past year
<br />® Natural ❑ Homicide
<br />❑ Driverloperator
<br />(w.)
<br />❑Pregnant at lima of death
<br />❑ Accident ❑ Pending Investigation
<br />❑ Passenger
<br />❑YES NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Suicide ❑ Could not be determined
<br />❑ Pedestrian
<br />Not pregnant, but pregnant 43 days tot year before death
<br />❑ Other (Specify)
<br />TO COMPLETE CAUSE OF DEATH?
<br />d
<br />❑ Unknown if pregnant within the past year
<br />❑ YES ❑ NO
<br />E22a.
<br />DATE OF INJURY (Mo., Day, Yr.) 12
<br />2b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />DESCRIBE HOW INJURY OCCURRED
<br />6
<br />I
<br />[]YES ❑ NO
<br />1229.
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYrrOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b.
<br />TIME OF DEATH
<br />113
<br />April 23, 2009
<br />z
<br />.91
<br />r
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />_
<br />23c, TIME OF DEATH
<br />1
<br />24C. PRONOUNCED DEAD (Mo., Day, Yr.) 24d.
<br />TIME PRONOUNCED DEAD
<br />$g z
<br />Aril 23, 2009
<br />06:15 AM
<br />'
<br />O
<br />$
<br />3d. To the best of my knowletitle, death occurred at the time, date and place
<br />due to the
<br />24s. On the basis of examination and/or Investigation. In my opinion death occurred at
<br />and "use(s) Stand. (Signature and This)
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />Jennifer King, MD
<br />$ k
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />28b. WAS CONSENT GRANTED?
<br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN
<br />❑ YES ® NO
<br />I Not Applicable If 28a Is NO ❑ YES ❑ NO
<br />27. RNME, TITLE AN UlRFU5 OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNT? yps or Print)
<br />Jennifer King, MD, 2300 West Capital Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE 28b.
<br />DATE FILED BY REGISTRAR (Mo,, Day, Yr.)
<br />April 27, 2009
<br />
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