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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 ORICaINAL RECORD ON FILE WITH THE NEBRASKA c~~Rfih~~n116gr~ HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITA~`R~~~9Rd~. ~~ ; ;
<br />DATE OF ISSUANCE 'r ~ r / 8
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<br />LINCOLN, NEBRASKA HUMAl~ SERVICES ,~ ,: ,.d
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<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPP©^ '! ~ : ~ ^` ..-
<br />CERTIFICATE OF DEATH "~
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<br /> _ 1. DpCEDENT'S-NAME (First, Middle, Lasl, Suffix) 2. SEX 3. PATE OF DEATW (Mo., Day, Yr.)
<br /> Jud ann Patterson Female Auu
<br />st 2, 2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH ea. AGE•Last Birthday 6b. UNDER 1 YEAR 5c. UNDER 1 DAY _
<br />6. BATE OF BIRTH (Mc., pay, Yr,)
<br /> (Yrs.) MOS. DAYS HOURS MINE.
<br /> Che enne Wells, Colorado_ 64 May 3, 1945
<br /> 7. SOCIAL SECURITY NUMBER _
<br />Ba. PLACE OF DEATH ~~
<br /> ~;S (~~. ~ 9 [u 7 _~ _ kiO.SPJSBL: ~ Inpatient OTHER ^ Nursing Home/LTC ^ Hospice Facility
<br /> Bb. FACILITY•NAME (If not Inelltution, give street and number)
<br /> ^ ERlputpatlent ^ Decedent's Home
<br />;, St. Francis Medical Center
<br />~ Q pea ^Other (Speoify)
<br /> 8c. CITY OR TOWN OF DEATH (Include Zlp Code) ~ 8d. COUNTY OF DEATH
<br /> Grand Island N breaks _ 1
<br /> 9a. RESIDENCE•$TATE 9b. COUNTY BC, CITY OR TOWN
<br /> Nebraska Ha11 Grand Island
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<br />8d.8TREETANbNUMBER Oe.APT.NO 9t. ZIPGDDE 9g.IN51DECI7YLIMITS
<br /> 2118 W. Koeni St . _ ~ Yes ^ No
<br />- -. 688
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<br />10a. MARITAL STATUS AT TIME OF DEATH ~1
<br />Married ^ Never Married 10b. NAME OF SPOUSE (First, Mlddle, Last, Suffix) If wife, give maiden name.
<br />_ - ^ Married, but separated 0 Widowed ^ Diverted ^ Unknown
<br /> Johnn M. Patterson
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<br />~ 11. FATHER'S-NAME (First, Middle Laet, Suffix) 12. M07HER'S•NAME (First, Middle, Maiden Surname)
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<br />~,-: ". 3' -C. _. ._ son___
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<br />13. EVER IN U.3. ARMED FORCE57 Give dates of service if yes. 14a.INFORMANT--NAME 146, RELATIONSHIP TO pECEDENT
<br />i.~ (Yas,nc,orunk.) No _ Johnn M. Patterson Husband
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<br />t5. METHOD DF DISPOSITION tea. EMBALMER-SIGNATURE 186. LICENSE N0. 16c. pATE (Mo., Dey, Yr. )
<br />OBUrlal ^Doneticn No_t_ Embalmed Au ust 31
<br />2009
<br />, 4: ,_.,
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br />[Cremation ^ Entombment
<br /> ^ Removal ^ Other (Specify)
<br /> Westlawn Crematory Grand Island, NE
<br />_- 77a. FUNERAL HOME NAME AND MAILING ADDRESS ($treBl, Clty ar Town, State) 176. Zip Coda
<br />.a~a Livingston--Sondermann F.H. 601 N. Webb Rd. Grand Island, NE b$803
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<br /> 18. PART I. Enter the chain of events--diseases, injuries, or campllCadpns••ihat dlre0tly Caused the death. pp NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />
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<br />~' respiratory arrest, or ventricular fibrlllatlon without showing the etiology. DO NpT ABBREVIATE. Enter only one cause on a Ilne
<br />Add eddltltlnel Ilnas if necessar
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<br />nr:• IMMEOIATECAUSE: I tlneettodeeth
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<br />IMMEDIATECAUSE(Flnel (a) ~4 1 ~ M w a~ r ti ~+`1 ~ ~~~, w J ,~A ~ V~4• ~.rr ~h
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<br />~ tg DUE T0, DR AS A CONSEQUENCE OF: I onset to death
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<br />~ Indi~th) I
<br />
<br />~~ Spuentlslly Ilst ctlndltltlne, If ~) I
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<br />~y;' any,leadingtothecauaellsted DUE TO, ORA5ACONSEgUENCEOF; I onset to death
<br />,,,;~ on Ilne a.
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<br />Enferihe UNDERLYING CAUSE
<br />';~,~•'Y. (disease or ln)ury that initiated (0) I
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<br />~, the events naulllrg In des}h) DUE TO,OR ASACONSEDUENCE OF: __._~ _ I Onset itl tleatn
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<br />{ •', 18. PART IL OTHER SIGNIFICANT CDNDITIONS•Condltl0ns Contributing to the death but net resulting In the underlying cause given In PgRT I. 1g. WA3 MEDICAL EXAMINER
<br />a, ~
<br />OR CORONER CONTACTEp7
<br /> ^ YES NO
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<br />y20. IF FEMALE: .... 21a.MANNER OF DEATH _ 216. IF TRANSPORTA7IDN INJURY 21c. WA$AN AUTOPSY PERFORMED?
<br />C~~Not pregnant within past year x ~}latural ^ Homicide ^ DrivedOperator 'k
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<br />,~ ' Accident0 pending Investigation ^ Passenger ^YE5 ~P10
<br />^ Pregnant at time of death
<br />^
<br />~y,
<br />',.r~ Q N01 re Went, but re Want within 42 tla s of death ^ Pedestrian
<br />p g p g y ^Suicide ^COUldnotbedefermined 21d.WEREAUTOPSYFINDING3AVAILABLETO
<br /> ^Other (Specify) ~
<br />^ Nofpregnan6 but pregnant 43 days to 1 year before death COMPLETE CAUSE pF pF1QH7
<br /> ^ Unknown if pregnant within the past year •,.•,._,..- G YE5 D
<br /> 22a. DATE OF INJURY (MO., pay, Yr) ~.....- _. - ................_. .._...•_ __....~
<br />22b. 7tME OF INJURY 220. PLACE OF INJURY•At home, !arm, street, factory, office building, oansiruCtlon Bite, etc. (Specify)
<br /> ~
<br />~R 22d.INJURV AT WORK? 22e. DESCRIBE HOW INJURY
<br />OCCURREb
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<br />%* ^ YES ^ NO
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<br />',A" ~ 22f. LOCATION OF INJURY -STREET 8 NUMBER, APT. N0. CITY/tOWN ~ STAIE ZIP CODE
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<br />23a. DATE OF DEATHOMo. Day, Vr.) ¢ 24a. PATE 81GNE0 (Mo., Day, Yr.) 246. TIME OF DEATH
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<br />23b. DATE SIGNED Mo. Day, Vr) 23c.TIME pF DEATH ~ ~ ~
<br />240
<br />PRONOUNCEDDEAD (Mo., Da ,Yr. 24d. TIME PR
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<br />~ y ) ONOUNCED DEAD
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<br />my knowledge, death occurred at the time, date and place
<br />24e. On the basis of exarnlnatlon and/or investigation, in my opinion death occurred at
<br /> CL end due to the cause(s) stated. (SI nature and Title) • e ~ p the time, date and p1a06 and due to the cause(s) staled. (Signature and Title)
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<br /> ~5.DIDTQBACCOUSECONTRIBUTETOTHEDEATW? 26e,HA50RGANpRTISSUEDONATIONBEENCONSIDEREp9 26b.WA5CONSENTGRANTED?
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<br /> Ll YES 0 ^ PROBABLY _^ UNKNOWN
<br />^ YES NO Not Applicable If 28a le NO ^ YES ^ No
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<br /> V,NAME. TITL AN AD RESS OF CERTIFIER PH
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<br />YSICIAN, CORONER'S PHYSICIAN OR COUN A NEV) Type Or Prlgl) q
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<br /> 28a. REGISTRAR'S SIGNATURE 286, GATE FILED BY REGISTRAR (MO., Day, Yr,)
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<br />HHS-61 11 /03 (55081)
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