|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF H~`~IL"jH~A1~1P,H(J/~1;4N SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBl~.4$1fA:DEP.~R'}`MENT;,pF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY F'OR~"VII'I~I, j3L~~5` ~~„ ~ ~.
<br />~ ~~
<br />DATE OF ISSUANCE
<br />JUL 2 8 2A09 ~ O ~ ~ 0 8 Q ( ( ~ `;rA55I,S AI~T°S a~ ~ REGISTR~{R
<br />B~FARTMENT OF HE,QLTFi' AND
<br />LINCOLN, NEBRASKA KUM,gI'cj o~,~RVICE,~'"` '~ - °
<br />;', ...
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE ANL15{J~ p~
<br />CERTIFICATE OF DEATH - ~~~ .~E.7e~~4.
<br /> 1. DECEDENT'S•NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF pEATH (Mo., Dey,Yr.)
<br /> Irene Mary McConnell Female _Jnly 20, 20~
<br /> _
<br />4. CITY AND 97ATB OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE•Lasl Birthday 5b. UNDER i VEAR 5C. UNDER 1 DAY 6. DATE OF BIRTH (MC., Day. Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br /> Genoa, Nebraska 99 September 13, 1909
<br /> 7.30CIAL BECURITY NUMBER __._ 8e. PLACE OF DEATH
<br /> •rj0]-rj(}•.•47$~ H9.SPLTdL; ^Inpatlent QTI$B: $INUrsingHome/LTC ^HosplceFacility
<br /> ~
<br /> 86. FACILITY-NAME (If npl institution, glue street and number) -
<br />^ ER/Oulpalient ^ Decedent's Home
<br /> Tiffany Square Care Center ^ IXN ^Other(Spaclly)
<br /> 8c. CITY OR TOWN OF pEATH pnclude Zip Code) ~ 8d. COUNTY OF bEATH
<br /> Grand Island 68803 Hall
<br />~ m^
<br /> 9a. RE8IDENCE-STATE 9b.000NTY Oc. CITY DR TOWN
<br /> Nebraska Hall Grand Island _ _ _
<br /> 9d.STREETANDNUMBER ~ ~ 99. APT. NO 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 1420 N. Lafayette Ave. __68803 Xl YES `^ NO
<br /> 1ge. MARITAL STATUS AT TIME OF DEATH ^ Ma«ied ^ Never Married 1l)b. NAME OF SPOUSE (First, Middle, Lae6 Sulllz) If wife, give maiden name.
<br />
<br />~ ^ Married, but separated g[Widowed ^ Divorced ^ Unknown
<br />,~ 11. FATHER'S•NAME (First, Middle, Lasl, Suffix) 12. MOTHER'S•NAME (First, Middl9, Maiden Sumeme)
<br />•~~' Elmer Killham Lula Mae Kinzer
<br /> 13. EVER IN U.S. ARMED FORGE57 Give dates of 6erVICa if yes. 14a. INFORMANT-NAME 146. RELATIONSHIP TO DECEDENT
<br />4`" (Yes,np,orunk.) No Verna McConnell Daughter
<br />'
<br />
<br />~. 15. METMODDF DISPOSITION
<br />
<br />Iy~Surial ^Donatlon 16a.EMB LMER-51GNAT RF~~ 1Bb. LICENSE N0. i8c. DATE (Mp., Dey, Yr. )
<br />~~rNV+7( /ad7~1~ ~uxy z3, zoo9
<br />`r'
<br />^ Cremation ^ Entombment 18d.CEMETE ,GREMATORYOR THERLOCATION CITY/TOWN STATE
<br /> ^Removal ^Other(Specily) Central City Cemetery, Central City, Nebraska
<br /> 17a. ~' ' ~:-AL HOME NAME AND MAILING ADDRESS (Street, City or Town, S(alB) 17b. Zlp Code
<br /> A,,1e1 Funeral Home, 1123 West Second, Grand Island, Nebraska. 6$801
<br />t ~~ -
<br />- 18. n4RT f. Borer me enam nt_eyyy7,~••dieea9ee, ivfdrive; or Cpmpikatlons--rilut d~uily eauaed uie deaih.BG tiDT enter ter,ninai evens aaph esr:crdiac srraat, APPRDXIM.ATE INTERVAL.
<br />I
<br /> respiratory arrest, or ventricular fibrillalldn without showing the etiology. DD NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it neces6ary. i,
<br /> IMMEDIATE CAUSE: I onset to death
<br />I
<br />~ I
<br />~• IMMEDIATE CAUSE (Final (a) _ -,~'„~~ ~ L......
<br />._ ~~..____m_ .. ,_
<br /> dlaeea~or condition resulting pUE TO.OR A5AC NSEOUENCE OF: I onset to death
<br />• ~:`', In death) I
<br />,1, ~~ Sequenllally list conditions, It (b) ~~ ~ ~ b _ I ~$
<br />~
<br />
<br />
<br />r any,leadinglomecauaallated -- ~~ ~~
<br />I onaettodeath
<br />DUE T0, OR AS A CONSEOU E OF:
<br />;~ a onllnea. I
<br />'.1 r Enterih~UNDERLVINGCAUBE I
<br /> (dlaeeasorin~urythatlnltlated (°) _,,,,_ I •..,,^
<br /> the events reeuhing In death) pUE TO, OR A5ACON5EDUENCE OF: I onset tv death
<br /> ~~ I
<br /> (d) I _ _
<br />f
<br /> 19. WAS MEDICAL EXAMINER
<br />18. PART IL OTHER SIGNIFICANT CONDITIpNS•Cpnditions contributing to the death but not resulting in the underlying Cause given in PART L
<br /> f OR CORONER CON CTED7
<br />
<br />M
<br />t
<br /> ~ ^ YES l7 NO
<br />~! ~~
<br /> 1
<br />IF FEMALE: 21a.MAyNEROFDEATH 216. IFTRAN5PORTATION JURY 21c.WASANAUTOPSYPERFORMED?
<br />2u
<br />r
<br />U D
<br />lO
<br />t
<br />rr ~
<br />/
<br />rrver
<br />pera
<br />o
<br />~~
<br />p Nat pregnant within pest year Natural ^ Womiclde
<br />LLTJO
<br />O
<br />. YES
<br />U Passen
<br />er
<br />
<br />^ g
<br />^ Pregnant at time of death ^ ACCldent^ Pending Investigation ..,,~_ „...._
<br /> ^ Nol pregnant, but pregnant within 42 days of death ^ Pedestnan 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />^ Suicide ^ Could not be determined
<br />`~
<br />'' OF
<br />DEATH7
<br />~ Not pregnant, but pregnant 43 deye t01 year belore death ^ Other (SpeCity) COMPLETE CAUSE
<br />.
<br />,.a. ~ ~
<br />/
<br />^ Unknown if pregnant within the past year ^ YES ~'18O
<br />- --. ..-
<br />_ 22a. PATE OF INJURY (Mv., Dey, Yr,) 226. TIME DF INJURV 22C. PLACE OF INJURY•At home, farm, street, laCtory, olllea building, construction BI1e, Ste. (Specify)
<br />
<br />
<br />(]
<br />y.
<br />
<br />
<br />
<br />2d.INJURY AT WO 7 ED _ -...
<br />
<br />__
<br />
<br />22e D
<br />.._-..
<br />- -_- .. ~ -
<br />~ _
<br />1]1E6-~ .... -
<br />.
<br />_... .-.--... .
<br />
<br />~j.~
<br />~iS 22f. LOCATION OFINJURV-STREETBNUMBER, APT,ND. CITY/TDWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) _ ~ 2aa. DATE SIGNED (Mo., Day,Yc) 24b.TIME OF DEATH
<br />
<br />July 2Q r 2089
<br />~'
<br />Z
<br />~'sst m
<br /> ~
<br />- .._
<br />~ 23¢.u~T~SIC~[JEb (Mp„)Z81(~r.) 23c.2M J~ EATH d m ~ ~ a 24C. PRONOUNCED DEAD (Mo., Day, Yr.) tad. TIME PRONOUNCED DEAD
<br />cJJ .[ LUU LL((~~ J n a y m
<br />a
<br /> Eq
<br />23d. To t of my knowl , death pC red at the time, date and place $ w ~ 24e. On the basis of ezaminatlpn and/or investigation, in my opinion death occurred at
<br />nature and Title)
<br />(Si
<br />e to the cause(s) stated
<br />d
<br />l
<br />d d
<br />~
<br />~
<br />h
<br />i
<br />d
<br /> .
<br />g
<br />p
<br />ace an
<br />u
<br />ale an
<br />~
<br />t
<br />e t
<br />me,
<br />and due tp a cause( staled. (Sign t re and Title)
<br /> ~
<br />~ ~ - ¢¢Q
<br />CJ $
<br /> 25. Dlp TOSACCD SE ONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 286. WAS CONSENT GRANTED?
<br /> ~
<br /> Npl Applicable if 28a is ND ^ YES a N0
<br />^ YES ^ PROBABLY ^ UNKNOWN ^ VE5
<br /> TIFIER (PHYSICIAN,CORONER'S PHYSICIAN OR COUNTYAT70RNEY) (Type orPrlnt)
<br />27.t~AME,TITLEA
<br />B
<br /> Ryan
<br />ch A.O. 800 N. Alpha Ave., Grand Island, NE. 68803
<br />~'rOU
<br /> 28a. rjEGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mp., pay, Yr.)
<br /> ~ . ~u~ ~ ~ zoos
<br />~~
<br />HH5-B1 11/03 (55061)
<br />
|