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<br /> 1. bECEbENT'S•NAME (First, Middle,T ~~.. Laet, Sulflx) 2. SEX 3. DATE OF DEATH (Mv., Dey, Yr.)
<br /> Wayne Julian Ashmore Male Septembez 2], 2009
<br /> ___
<br />4. CITY AND STATE OR TERRITDRV, OR FOREIGN COUNTRY OF BIRTH 59. AGE-Lest Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (MO., pay, Yc)
<br /> (Yrs.) MOS. DAYS HOURS MINE.
<br /> Camden County, Missouri 98 October 12, 1910
<br /> 7. SOCIAL SECURITY NUMBER _ Y Sa. PLACE OF DEATH
<br /> ] 11-D 1-09 rj ~} HOSPITAL: ^ Inpatient 9IIiEB: ^ Nursing Home/LTC ^ Hospice Facility
<br /> Sb. FACILITY•NAME (If not Institution, give street end number)
<br />$1 ER10utpatient ^ Decedent's Home
<br /> St. Francis Medical Genter p Daa ^other (Specity)
<br /> Bc. CITY OR TOWN OF pEATH (Include ZIp Cade) __ 8tl. COUNTY OF DEATH
<br /> Grand Island 688,03 Hall _
<br /> 9d. RESIpENCE•STATE 96, COUNTY 9c. CITY OR TOWN
<br /> Nebraska Hall Gx'and island
<br /> _
<br />9d.5TREETANDNUMBER ~_M 9e. APT. NO 9r. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 2114 N. HllStOn A1V~• 6$803 X^ VE5 ^ ND
<br /> 1ga. MARITAL STATUS AT TIME OF DEATH ^ Mprrled ^ Never Married 10b. NAME OF SPDUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />- p Me«led, but separatedWidowed ^ Divorced ^ Unknown
<br />-- tt. FATHER'S•NAME (First, Middle, Last Sufllx) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br /> Marion Ashmore Rosa _•.._ Hur t
<br />;a. ~, 13. EVER IN U.S. ARMED FDRCE5? Glvedates of service If yea. 1aa.INFORMANT•NAME 146. RELATIONSHIP TO DECEDENT
<br /> (Ves,no,orunk.) No Jeff Fulton Step-son
<br />,;~T,~ 15. METHOD OF DISPOSITION 18a. EMBA ER•51GNATURE
<br />~ 16b. LICENSE N0, 18c. bATE (MO., bay. Yr.)
<br /> g[Burial ^Donatlon ~.~ J~$ _ October 1 2009
<br />_
<br /> ^ Cremation ^ Entombment STATE
<br />tsd. CEMETERY, REMATDRY OR ER LOCATIDN CITY /TOWN
<br /> ^Removel pother(spetllfy) ~ Crown Hill Memorial Park Wheatridge, Colorado
<br />
<br />- 17a. FUNERAL HOME NAME AND MAILINp ADbRE55 (Street, City or7Cwn, Stele) _ 17b. Zip Code
<br />_ Apfel Funeral Home 1123 West Second, Grand Island, Nebraska 68801
<br />
<br />• 15. PARTI. Enter the chain of events••diseases, injuries, or compllcellons--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />I
<br /> respiratory arrest, Or ventricular Fibrillation without showing the etiology, DO NOT ABBREVIATE. Enter only pne Cause an a line. Add additional lines i} necessary. I
<br /> I onset to death
<br />IMMEbIATE CAUSE
<br />'•: h, p ~` may,.
<br />IMMEDIATE CAUSE (Final (a) F T ~\Q 'd+ ~\^ ~~ , , `~~ ..,.___.......~.. I
<br /> dlawaeordondhlonraeultkrg DUETO,ORA~EquEf CE OF: I CnsattOdeath
<br /> Ind~ih) I
<br />~''~' Saquantlallyllelcondltlona,lf (b) I
<br /> any,leadingtotnaceuaellated pUETO,DRASACON5E0UENCEOF: I Onset to death
<br /> on line e. I
<br /> Enter g1e UNDERLYING CAUSE
<br />I
<br /> (dleaeae vrlnJury Ulat lnlfletad (0)
<br /> itu awnternWtlnq In death) pUE TD, OR A3ACONSEOUENCE OF: ~ I vneet [0 death
<br /> lA4F I
<br /> (~ I
<br /> 15. PART IL OTHER SIGNIFICANT CONDITIONS•Conditions cvniri6uting to the death but npt resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED7
<br /> O YES ~I ND
<br />a
<br />w 20. IFFEMALE:R 21 e. NNEROFDEATH 21 b. IFTRANSPORTATIONINJURY 21c.wA5ANAUTOPSYPERFORMED7
<br /> ^ Nol pregnant within peel year Natural ^ Homicide ^ DrrvedOperator
<br />^ YES ~NO
<br />5 ^Pessenger
<br />^ Pregnant al lime of death ^ Accident^ Pending Inveallgatlon .,,....,
<br />.:;i -`
<br />- ^ Pedestrian
<br />^ NOt regnant, but pregnant within 42 day9 01 death ^ SuiCitle ^ Could not da determined 21 d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br /> U Nat pregnant, but pregnen143 days to 1 year before death COMPLETE CAUSE OF DEATH7
<br />~' ^ Unknown If pregnant within the peel year ^YE5 ^ NO
<br />_.._... .....,...
<br />~p
<br />3V~ , _m.__.,,. _...... _,__._, .... -. _.
<br />22a. DATE OF INJURY (Mv., Dey, Vr.) 226. TIME OF INJURY 22c, PLACE OF INJURY•At home, farm, street, factory, office 6uiltling, Construction site, etc. (Specify)
<br />
<br />+Yi~
<br />~. __._
<br />22d. INJURY AT WORK? .. ..
<br />22e. D'eSCRiBE HDW INJURY OCCURRED
<br />~' ~~
<br /> ^YE5 [] NO
<br />~
<br /> ZIP CODE
<br />221. LOCATION OF INJURY • STREET 6 NUMBER, APT. NO.~ CITY/fOWN STATE
<br />_
<br /> 24b.TIME OF pEATH
<br />23e. DATE OF DEATH (Mo., bay, Yr.) T x ~ 24a. DATE SIGNED (MO., Day, Yr.)
<br />'' S~- ntember 27, 2DQ4
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<br />23b. DATE 31GNEb (Mo., Dey, Yr.) 23C.TIME DF DEATH ~ ~ 24C. PRONOUNCED DEAb (MO., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />
<br />•
<br />~'~ J Y
<br />Se tember 28 2009 to `a x~x m
<br />~
<br /> ~ S ~ W ~ O 24e. On the basis of examination end/Or Inveellgallon, In my opinion death occurred al
<br />23d. TO the best of my knowledge, death oCCUfred at the time. detB and place
<br /> ~ ~ an due to t cause(s) tared. (Signature and Title) • g p ~ the time, date end place and due to the cause(s) stated. (Signature and Tltld)
<br /> r° ~o
<br /> a U ~
<br /> 25.pIDTOBA000U5ECONTRIBUTETOTHEDEATH? 268. HAS ORGAN ORTI$SUEDDNATIONBEENCONSIDERED7 28b.WA5CONSENTGRANTED7
<br />~- ` N
<br />^YE5 NO Q PROBABLY ^ UNKNOW C] YES NO Not Applicable 1128a Is ND ^ YE9 ^ NO
<br /> _
<br />27.NAME. TITL AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN pR COUN ATTORNEY) (Type Or PrlnQ
<br />~
<br />. Douglas Herbek, M.D. 2444 W. Faidley Ave.. Grand Island, NE 68803
<br />,
<br /> 28a. REGISTRAR'S SIGNATURE 2Bb. DATE FILED BY REGISTRAR (Mo., Dey, Yr.)
<br />- ~ ocr ~ zoos
<br />STATE OF NEBRASKA
<br />_~ ~
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT pF HEALTH AAVL~ Hlyl.M~ SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR.4SK~,'ID'•L~ W JV"!'~,?F HEAL7~i AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIT~1L,~t+~C~!~''~..1 `
<br />•A ~~ .W
<br />DATE OF ISSUANCE ~~~~~~ ~ `
<br />ocT ~ 4 zoo9 ST,4l1t/,.f3'S`: co~n~~r , , , . °~ .
<br />200908783 p~ ~r'~~ ~ ~`~~)~'
<br />LINCOLN, NEBRASKA HUMA(V~ i ~ <•; ,,.'
<br />~y',rk, r ~' '
<br />\ 1 ~ l.d f ... ,wy r..
<br />'1 ~ + ~y j 1 I ~ N.
<br />STATE OF NE6RASKA•- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPO ~ -7
<br />CERTIFICATE OF DEATH ~~ ~~~`~~ r
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