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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECC)RD ON FILE WITH
<br />THE NEBRASKA HEALTM AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH lS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE ,/" P,~~
<br />FEB o 4 Zaaa 200909894 ~ A T a~~~~~~
<br />LINCOLN, NEBRASKA H'EA4 ~ , W r HUA~4111'~R'~1'G~
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<br />STATE OFNEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVIG~ES FiNA1+JCEAND SUPPQr~ ti
<br />CERTIFICATE OF DEATH `, ~ "^;`'~` ,;, . ,~.~~#~." J~~~~
<br />1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 8 SE~r;; ~ •~ ^3.bAFEtYFD~YfH (Mo.,Day,vr.)
<br />James NOrman Benson 1~'alE'~ t,.., a r `.ixba'x-q 2b, 2008
<br />` 4. CITY AND STATE OR TERRITORY, OR FOREIpN COUNTRY OF BIRTH 5a. AGE•Last Birthday 56. UNDER 1 YEAR 5c. UNDEi~'tt'C~F1' .-~8: f~ATE,OF,..61RTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS ;MINS::'
<br />Grand Tsland, Nebraska 80 Apxil 16, 1927
<br />7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />506-22-5390 (dOSPITAL: ~ Inpetlent QT1dE$ ^ NuraingHome/LTC ^HoeplcaFecllity
<br />8b. FACILITY-NAME (If not Inatltutlon, glue elreet end number) ^ ER/Outpatient ^ Decedent'sHome
<br />St. Francis Medical Center ^ ppq ^pther(Specify)
<br />Bc. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />8a. RESIOENCE•BTATE gb. COUNTY 8c- CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />9d.5TREETAND NUMBER 9e. APT. NO 8f. ZIP CODE gg. INSIDE CITY LIMITS
<br />2106 Pioneer Blvd. - -" 68$01 ~ YFS c~ ND
<br />10a. MARITAL STATUS ATTIME OF DEATH L~Merried ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />^ Married, but separated ^ Widowed ^ Divorced ^ Unknown Mardell Grave 8
<br />11. FATHER'S•NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br />Arthur Benson Gertrude Gruben
<br />13. EVER IN U.S. ARMED FORCES? Glve dates of service If yea. 14e.INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />(1~s1'.rB,brunk.4k-20-1945 7-26-1946 Mardell Benson Wife
<br />15. METHOD OF DISPOSITION 16a. EMBAL R-SIGNATURE 186. LICENSE N0. 18c. DATE (Mo., Day, Yr. )
<br />(~Burlel ^Donetion / 0~8 Januar 30~ 2008
<br />^ Cremation ^ Entombment 16d. CEMETERY, C MATORY OR OTH OCATION CITY /TOWN STATE
<br />^Removel ^otner(speddy)
<br /> Grand Island Cemetery, Grand Island, Nebraska
<br />17a. FUNERAL HOME NAME AND MAILINp AODRE88 (Street, City arTown, State) 17b. Zlp Code
<br />Apfel Funeral Home 1123 West Secrand, Grand Island, NE 6$801
<br />1& PART I. Enter the chain of events--dlseaaea, InJurlas, or complications-•that directly caused the death. DO NOT enter terminal events ouch ae cardiac arrest, APPRO%IMA7E INTERVAL
<br />I
<br />resplrerory arrest, or ventrlculer flbrllletlon without ehowing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Ilnes If necessary. I
<br />IMMEDIAT USE:
<br />I onset to death
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<br />IMMEDIATE CAUSE(Flnal (a)
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<br />dlse9aewconditiunPoauldng DUET ORASACONBEQUENCEOF: I onsellodea
<br />In dstdh) I
<br />SequeMlelly Ilet condttlone, If lb) I
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<br />any,kadinglothecausellsted ~
<br />DUE T0, OR AS A CONSEQUENCE OF: I onset to death
<br />on Ilne a.
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<br />FsterlM UNDERLYINp CAUSR
<br />(dlesaseorlnJurythatlnlttated (c) I
<br />d»awntsreaulunglndeath) pUETO,ORA3ACONSEOUENCEOF: ~ I onset to death
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<br />18. PART ILOTHER SIONIFICANTCONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given In PART I. 1g. WAS MEDICAL EXAMINER
<br />~11
<br />~ OR CORONER CONTACTED?
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<br />~ ^ YES NO
<br />-z0..,lE.FEMALE: ~21a.&R OFOEAi'H-- 21 b. IF TRANSPORTATIONIRJURY 27c-WAS AN AUTOPSY PE FORMED?
<br />^ Not pregnant within past year Neturel ^ Womicide ^ Driver/Dperalor
<br />^ Pregnant at time of death ^ Accldent^ Pending Inveatigatipn
<br />^Pasaenger
<br />^YE5 NO
<br />^ Not pregnant, but pregnant wlthln 42 days of death
<br />Q Suicide ^ Could not be determined ^ Pedestrian 21d. WERE AUTOPSY FINDINGS AYAILABLE TO
<br />^ Nol pregnant, but pregnant 43 days to 1 year before death ^ Other (Specify) COMPLETE CAUSE
<br />OF
<br />DEATH?
<br />^ Unknown if pregnant wlthln the pest year ~~
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<br />^ YES L]'AO
<br />22a. GATE OF INJURY (Mo., Day, Yr.) 226. TIME OF INJURY
<br />m 22c. PLACE OF INJURY•At home, farm, etreel, factory, office bullding, construction alts, etc. (Specify)
<br />22d.INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />^ YE5 ^ NO
<br />22f. LOCATION OFINJURY -STREET 8 NUMBER, APT. Np. CfTY/tOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNEp (Mo., pay, Yr.)
<br />~~ 24b.TIME OF DEATH
<br />~ ~7anuary 26, 2008 ~, m
<br />23 IGNED(Mo.,Day,Yr.) 23c. IMEOF EATH _~ 24c
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<br />Day
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<br />TIMEPRONpUNCEpDEAO
<br />2008 ~:4~
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<br />23d. To th eat of my knowled e, dear occurred at the time, date and place
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<br />24a. On the basis of examination andlor investigation, in my oplnlan death occurred et
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<br />e) • ~ ~ the time, date end place end due to the cause(s) stated. (Signature and Tltla)
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<br />25.01 OBA O USE CONTRIBUTETOTHE DE 7 2sa. HAS ORpAN OR TISSUE DONATION BEEN CONSIDERED? 286. WAS CONSENT ORANtEp7
<br />
<br />Y ~D ^ PROBABLY ^ UNKNOWN
<br />^ YES MO ~
<br />Not Appllca6le 1128a Is NO ^ YES ®'NO
<br />27. NA E, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, GORONER'8 PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />John Wagoner M.D, $00 N. Alpha Ave., Grand Island, NE 68803
<br />28e. REGISTRAR'S SIGNATURE 2Sb. DATE FILED BY REGI8TRAR (Mo., Dey, Yr.)
<br />~ JA~f 31 20p8
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