|
STATE OF NEBRASKA "~"
<br />WHEN THIS COPY CARRIES THE RAISED SEAL DF THE NEBRASKA DEPART ~~~c t3k1~,4~?~`e A, b . OMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO 8E A TRUE COPY OF THE ORIGINAL RECORD ON FILE WN~~E. N ~ SKA'C:,1"MENT OF HEALTH ANp
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DE~O,~~OL~jl~ REr~pr~QS.
<br />-' : Y,r
<br />PATE OF ISSUANCE ,~i01~~X/1.
<br />MAR o s 20D9 2 4 4 9 0 9 8 3 4 ;, ~.._ ASSIST F~t~ r€AirH ANp
<br />- 1
<br />LINCOLN, NEBRASKA "'~ ~ DEP,YtR'T
<br />, ~,~ _, .p,~l~~ -
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND H~~IAN Si~~CiE$ '~~-~ 9 2 ~ g 7 7
<br />f:FRTIFIC:eTF AF I~FATI.1
<br /> 1. DECEDENT'S-NAME (Piny Middle, Last' Suffix) R SEX 3. DATE OF DEATH (Mo.,Oay,Yr.)
<br /> William Robert Fagan Male February 27, 2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 8a. AGE-Lea! Blrfhday 8b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE qF BIRTH (Mo., Day, Yr.)
<br />'~ (Yrs.) MOS. DAYS HOURS MINE.
<br />' Grand Island, Nebraska 85 November 2, 1923
<br /> 7.80CU1L SECURITY NUMBER 8a. PLACE OF DFJITH
<br />~ 507-48-5888 tf9&PITAL: ®Inpatlem S2IHEB: ^ Nureinq Hwne/LTC ^ Hoapica Facility
<br /> ab. FACILITY•NAME pf hoe InaBtullon, give etraet and number) ^ ERlputpaUent ^ DecedenPs Hams
<br />a Saint Francis Medical Center ^ DOA ^OthegSpacgy)
<br />m
<br />T 8c. CITY OR TpWN OF DEATH Qncluda Zip Code) ed. COUNTY OF DEATH
<br /> Grand Island 68803 Hall
<br /> sa. RESIDENCE-STATE 9b. COUNTY &. CITY OR TpWN
<br />~, Nebraska Hall Grand Island
<br />a
<br />~
<br />9d. STREET AND NUMBER
<br />9a. APT. NO.
<br />9f. ZIP CpDE
<br />9g. INSIDE CITY LIMITS
<br />~ 1908 W. Oklahoma 6gg01 ®r.a ^ No
<br /> 10a. MARITAy 9TATU8 AT TIME OF DEATH ®Merrirrd ^ Never Martled 18b. NAME OF SPOUSE (Flay Middle, Last' Suffix) K wih, glue maiden name.
<br /> ^ Married, but aepanted ^ Widowed ^ Divorced ^ Unknown
<br /> Darlene Puncochar
<br />4
<br />~ 11. FATHER'S-NAME First' Middle, Lea Suffix
<br />( t' 1
<br />12. MOTHER'S-NAME (Piny Mlddls, Malden Surname)
<br />O
<br />~
<br />William Fa an
<br />Marie Baker
<br />y
<br />m 13
<br />EVER IN U
<br />S
<br />A
<br />F
<br />
<br />O
<br />~ .
<br />.
<br />.
<br />RMEp
<br />ORCES? Give dates of service If Yq.
<br />(Yea, No, or Unk.) NO 14a. INFORMANT-NAME
<br />
<br />Darlene Fa an 14b. RELATIONSHIP TO pECEDENT
<br />
<br />Wife
<br /> 16. METHOp OF DISPOSITION 16a. EMBALMER-SIGNATURE 186. LICENBE NO. 18c. DATE (Mo., pay, Yr.)
<br /> ^a°dal ^b°mta°"
<br />C
<br />ti Not Embalmed Februa 27, 2009
<br /> ®
<br />nma
<br />°n ^Ent°mbment
<br />^ Ram°val ^rnhegap.clry)
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITYr'I'OWN STATE
<br /> Central Nebraska Cremation Service Gibbon Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING pppREBS (Street' Clty or Town, Step) 17b. Zip Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> CAUSE OF DEATH See instructions and exam lea
<br /> 1t. PART I. Enar ih. them m.v.rre. _ maaaa, IMudea, or compllc+dons-Mat olncgy cauwa dr d.qh, pp NOT xtpr wminal awnu .uch u raNkw emay t APPRQXIMATE INTERVAL
<br />respiratory arrest, or vanMCUlar n6rllletlan without showing the etlvl°®y. qq NOY A9aREVIATE. Enbr only one cause on a Ilea. Add atldxivnal lino H neeeuary.
<br />I
<br /> IMMEDIATE CAUSE: ~ onset to death
<br /> IMMEDIATE CAUSE (Final ))~ ,
<br />I
<br />disease or condidon resulting a)
<br />~-F,
<br />I
<br />M
<br />~-
<br /> ~
<br />~
<br />Q O M I
<br />~,
<br />t.
<br />~,5
<br />In death) // // l ( (k
<br />
<br /> DUE 70, OR AS A CONSEQUENCE OF: ~ onset to th
<br /> $equandally Ilet cdnditione, If ~
<br />b)
<br /> t
<br />any, leading to fhe cause listed
<br /> online a. DUE Tp, OR A$ A CpN8E0UENCE OF: t onset to death
<br />i
<br /> Enter the UNDERLYING CAUSE e) i
<br /> (disease or injury that initiated '
<br /> the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF; , onset to death
<br /> LABT ~
<br />1
<br /> d) ~
<br /> 18. PART IL OTHER SIGNIFICANT CONDITIONS-0ondiUane contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EICAMINER
<br /> OR CORONER CONTACTEp7
<br /> ,~ YES ^ NO
<br />0:
<br />W
<br />k 2g. IF FEMALE: 21a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJURY 21c. WAS AN AUTpPSY PERFORMED?
<br /> ^ Not pngnant within peat year
<br />^p
<br />t Natural ^ Homklde ^ pr(varlOparator ^ YES ~NO
<br />ly ngnan
<br />at Uma of deaM ^ Accident ^ Pending Imesdgation ^ Passenger
<br />(~
<br />^ Not pngnant' but pregnant within 42 Jaya of death
<br />^ Suicide ^ Could not be determined
<br />^ PadeatHan 21 d. WERE AUTgP$Y FINDINGS AVAILABLE
<br />
<br />^ Not pngnant' but pregnant 43 days to 1 year bsforo death
<br />^ Other (Specify) Tp COMPLETE CAUSE OF DF1tTH7
<br />^ YES ~ NO
<br /> ^Unknown if pragnam within the pant year
<br />m
<br />n
<br />O 22a. DATE OF INJURY (Mo., Dsy, Yr.) 226. TIME OF INJURY 22c. PLACE OF INJURY-A! home, farm, atroay factory, affla building, conetreCdon alto, etC. (Specify)
<br />t)
<br /> 42d.1RJINC! ilT WOR%Y 7Zs. Dt'~CRIBE -IDhf IN,IU)CM'OOCUAI~Lro.. ... .' ... ~ :.:, „M~ w . ~ ~.
<br />O
<br />~
<br />^ YES ^ NO
<br />~, 22f. LOCATION OF INJURY -STREET It NUMBER, APT. NO. CITYrtDWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mq„ Day, Yr.)
<br />Z
<br />~'a
<br />' R4a. PATE SIGNED (Mo., Day, Yr.) 244. TIME OF DEATH
<br /> ~
<br />ebruar 27 2009 ~~~
<br />u m
<br /> rn 23b. DATE ION Mo., Day, Yr.)
<br />J 23c. TIME OF pFATH ~ ~ O 24c. PRONOUNCED DEAD (Mq., Day, YrJ 24d. TIME PRONOUNCED pEAp
<br /> E~~ Z L~ ~
<br />Q 4:0.0 a.m. E~6x
<br />
<br />4 m
<br /> ~
<br />e 23d. Te the W y k owledge, death occumd a! the time, date and place ~ W 34e. On the basis tx examination and/or InveaUgation, In my opinion death occurred
<br /> e m and due o a dau a(a) stated, (Slgnatun and Tlt ,g ~ 70 at the time, date and place and due to the cause(s) stated, (Signature and Title)
<br />
<br />~+ 2E, DID TOBACCO CONTRIBUTE O THE DEATH? ~ 26a. NAS ORGAN OR TISSUE DONATION BEEN CONSIDEREp7 28b. WA8 CONSENT GRANTEp7
<br /> ^ YES NO ^ PROBABLY ^ UNKNOWN ^ YES ~ Nq Not Applicable K 28a is NO ^ YE5 ~ NO
<br /> 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORpNER'8 PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br /> Txavis Ha eman M.D. 729 N. Custer Ave. Grand Island Nebraska 68803
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />P ~
<br />~ ~ ~aa ~ zoos
<br /> ,
<br />,
<br />:•~
<br />
<br />v
<br />
|