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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 />r THE BELOW TO BE A TRUE COPY pF THE ORIGINAL RECORp ON FILE WITH THE NEBRASKA D~P,~ZTMENT OF HEALTH ANp
<br />HUMAN SERVICES, VITAL RECORpS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR ~/F~AL F{F.~~ r~5".
<br />DATE OF ISSUANCE ~~r'
<br />/~~~ •-
<br />~T74~N~tEy~S. COOP~R~ '~. :", ~~',
<br />07/01 /2009 ~ ~ ~ 3 V ~ 3 ~ ~ : ~A,'FSTANT STATE REGISTRQI~~
<br />' ~ ~PART~~D~ H~1 LTH:ANDr
<br />LINCOLN, NEBRASKA . ° ~dMA/V~ t(~ .~~r ":= ',,1
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTW AND HUMAN SER ICES t a"f 09 01398
<br />CERTIFICATE OF DEATH ~ ' ~''t=•,~ `~~~ ~~
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suttlx) ~ 2. SGfX J .. , '~:. ATE,.q 'DEATii (Mo., Day, Yr.)
<br /> Charles Max Derrickson Maie> ~ ' ,,' ~ i , • - •J ne ~6; X009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF 81RTH 5a. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER ~pAV ,B,.pATJ; OF 81RTH (Mo., Day, Yr.)
<br />.
<br /> IY-~d MOS. PAYS HOURS MINE.
<br /> Pleasantville, Iowa 84 December 15, 1924
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 484-22-1206 HOSPITAL ®Inpatlent OTHER ^ Nuning Home/LTC ^ Hospice Facility
<br /> 86. FACILITY•NAME (IT not Instltutlon, give street and number) ^ ER/Outpatiem ^ Decedent's Home
<br />K
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<br />Saint Francis Medical Center
<br />^ DOA ^ Other(SpecHy)
<br />~ 8c. CITY OR TOWN OF DEATH (Include Zlp Code) 8d. COUNTY OF DEATH
<br />a Grand Island 68803 Hall
<br /> 9a. RESIDENCE-STATE 9b. COUNTY ec. GITY OR TOWN
<br />z Nebraska Hall Grand Island
<br />~ 8d. STREET AND NUMBER 9e. APT. NO. 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 311 E. South St. 68801 ®YES ^ NO
<br />ro 1ga. MARITAL STATUS AT TIME OF DEATH ®Man'led ^ Never Married 196. NAME OF SPOUSE (Flrat, Mlddla, Last, Sufflx) H wife, glue maiden name
<br />d
<br />!E
<br />m
<br />^ Married, but separated ^ Widowed ^ Divorced ^ Unknown
<br />Marcella IoUISe BIUe
<br /> 11. FATHER'S-NAME (FIrsL Middle, Last. Suffix) 12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br />~ Charles Derrickson Myrtle Rogers
<br />a
<br />E 13. EVER IN U.S. ARMED FORCES? Giva dates Oi service If Yea. 14a. INFORMANT-NAME 146. RELATIONSHIP TO p6CEDENT
<br />$ (Yes, No, Dr unk.) Yes 04/23/1943-11/12!1946 Marcella Louise Derrickson Wife
<br />,J01p 1S. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 166. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />~
<br />~ ^ Burial ^ Donation
<br />Daniel D Naranjo
<br />1071
<br />July 1, 2009
<br /> ®Cremation ^ Entombment
<br />
<br />^ Removal ^ Other (Specl(y) 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> Central Nebraska Cremation Services Gibbon Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City Or Town, State) 17b. Zip Code
<br /> All Faiths Funeral Home, 2929 5. locust Street, Grand Island, Nebraska 68801
<br /> A F DEA H See instruct one an exam es
<br /> 1s. PART 1. Enter the chain o(avanfs--dlaasaes, InJunea, or compllcatlona-that dlractry cauaad the death. DO NOT enter leonine! events such as cardiac arrest, ; APPROXIMATE INTERVAL
<br /> respiratory amat, or ventricular abnllatlon without ahowlnp [he etlolopy. Dq NOT AgBREVIgTE. Enter only one cauw on a Ilne. Add additional Ilnea I( nacesesry.
<br /> IMMEDIATE CAUSE: pnset to death
<br /> IMMEDUITE CAUSE (Final al Respiratory Failure ;Hours
<br /> dlsaaas ar condhlon resuhina
<br /> in death) DUE TO, OR A5 A CONSEQUENCE OF: Dttset to death
<br /> Sequentially Ilrt Conditions, rc b) Pneumonia ;Days
<br /> any, leadlnp to the cauaa listed
<br /> Im Ilne a. DUE TO, OR AS A CONSEQUENGE OF: ; onset to death
<br /> Entartha UNDERLYING GAUSE ~) Chronic Obstructive Pulmonary Disease ;Years
<br /> (dlaeaae or Injury that Initialed
<br /> the events rosuRinp In death) pUE TO, OR AS A CONSEQUENCE OF: Onset to death
<br /> LP'$T d) History Of 7obaGCO Abuse ~ Years
<br /> 18. PART II.OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> Dementia, Hypertension, Coronary ARery Disease OR CORONER CONTACTEp?
<br />~ ^YES ®NO
<br />~
<br />LL 20. IF FEMALE: 21 a. MANNER OF pEATH 216. IF TRANSPORTATION INJUR 27c. WAS AN AUTOPSY PERFORMED?
<br />~ ^ Not propnam wnnin part year ®Naturol ^ Homicide ^ DnverlOperator
<br />U ^ Propnant at nme or death ^ Accidem ^ Penalnp Inveallpatlen ^ Paaaanper ^YES ®NO
<br /> ©Not prepnaM, but prepnaM within 4Y days of death
<br />^ swdde ^ Could nm be aewrmined ~ paaennan 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />
<br />^ Not proanaM, but prepnaM 4, aayt to t year before aeatn
<br />~ Otnar (specify) TO COMPLETE CAUSE OF DEATH?
<br /> ©Unknown If prepnaM wahln the pant year
<br />^ YES ^ NO
<br />a
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, ottlce building, construction site, etc. (Specify)
<br />0
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<br />~ 22d. INJURY AT WORK? 22a. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />t'
<br />^YES ^ NO
<br /> 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY!'1'OWN STATE ZIP CODE
<br /> 23a. PATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> ~ ~ June 26, 2009 ~
<br />S ~
<br /> r 236. DATE SIGNED (Mo., Day, Yr.) 23c. TIME pF pEATH ~ ~ ~ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> e -~ June 29 2009 08:42 PM Y
<br />~ ~ ~
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<br /> Sd
<br />7o the best of my knowledge
<br />death occurred at the ame
<br />date and place ~ e
<br /> .
<br />,
<br />,
<br />$ and due to the causals) stated
<br />(Sl
<br />nature and TItl
<br />)
<br />p Poe. On the basis Cf axaminatlon andlCr Inves[Ipatlon, In my Cpinlan tleath Occurred at
<br /> .
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<br />9
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<br />~ $$$$ ~
<br />~ ~ a the time, date and place and dub to the caueelrl dated. (Slpneturo and Title)
<br /> Jay C. Anderson, MD
<br /> 2S. Dlb TOBAGCO USE CONTRIBUTE TO THE DEATH7 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br /> ® YES 0 NO ^ PROBABLY ^ UNKNOWN ^YES ®NO Not Appllul6le M 28a is NO ^YES ^ No
<br /> 1 ( IAN, R P ype or riot
<br /> Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 286. DATE FILED BY REGISTRAR (MO., Pay, Yr.)
<br /> June 29, 2009
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