|
~a
<br />~.
<br />STATE OF NEBRASKA _-=
<br />,WNEL~(.THIS_CORY CARRIES THE RAISED'SE~TL C3F THE NEBRASKA DEPARTMENT OF HEALTl.L~IIOD kiUNMA11f',~~~2VICE5, IT CERTIFIES
<br />THE BELOW TO 8E A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRArb"RA~~P;4RTMC~VT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY P'OR~%I~AL•RR~C~ ~ S.• •, '.;: ~ ,
<br />,a., f /~~, °~ , y .
<br />DATE OF ISSUANCE L.! ~!rr~,
<br />OCT = g 2009 2 0 0 910 21 S A ~ N+ "~1~,TRE~.~rSTl~A~2'• N~
<br />'~ P~TMENT OF FIEALTH AND;
<br />LINCOLN, NEBRASKA H~M,~F1)J'~F.J~j,VICLFS , ,' ,',
<br />.r ,~, ..... ~:1 .,
<br />~ ' ; -•• .~
<br />, •,,.,~
<br />STATE OFNEBRASKA •- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORTn 9, r}~Q,~ (1 •~
<br />I~CCTI GIf~ATC AC 11C A•ru l 1 r .~i l 1
<br /> 1. DECEDENT'S•NAME (Flret, Middle, Leet, Suffix) 2. SEX 3. DATE OF bEATH (Mo., Day,Yr.)
<br /> _ Ronald _ Wayne _ Beck Male Octoher 12, 2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FDREION COUNTRY OF BIRTH 5a. AGE-Last Birthday 56. UNDER 1 YEAR 5c. UNDER 1 DAY B. DATE OF BIRTH (Mo.. Day, Yr.)
<br />
<br />Wallace, Nebraska (Vre.)
<br />75 MOS. bAYS HOURS MINS.
<br />June 23, 1934
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE pF DEATH
<br /> 506-40--0067 LiQSP_ILAL; ^ Inpatient 4THE9: l~l Nuraing HOmelLTC ^Hospice Facility
<br /> w
<br />Sb. FACILITY•NAME (II not Institution, give street and number)
<br /> ^ ER/Outpatient ^ Decedent's Home
<br /> Wedgewood Care Center
<br /> ^ DOq ^O1her(Speclty)
<br />- Bc. CITY pR TOWN OF DEATH (Include Zlp Cbde) _ Bd. COUNTY OF D6ATW
<br /> _ Grand Island _ _68803_.-- - ._
<br />~
<br />~
<br />~
<br />W Hall __ -.
<br />
<br />ga. RESIDEN
<br />C
<br />E-STATE _ _
<br />9b. COUNTY ___ __
<br />9c. CITY OR TOWN T~
<br /> Nebraska Ha11 Grand Is1an
<br />d
<br /> _
<br />gd. STREET ANDNOMBER _
<br />9e. APT. NO _
<br />TB1. ZIP CDDE
<br />Bg. IN310E CITY LIMITS
<br />', 309 West 8th St• _ _ 1 68801 gl YES ^ ND
<br /> 10a. MARITAL STATUS ATTIME OF DEATH f~Marrled ^ Never Married .
<br />10b. NAME OF SPOUSE (FIre6 Middle, Lest, Suffix) II wile, glue maiden name.
<br /> ^Marrletl,butseperated ^Wldowed ^Divorced ^Unknown
<br />_~...- r..._.__ Betty Freeland
<br />
<br />11. FATHER'S-NAME (Firer, Middle, Last, 5ufllx) _ -
<br />12. MOTHER'S•NAME (First, Middle, Maiden Surname)
<br />~F, T Harvey Beck Edna
<br />L. Boehn
<br /> _ _
<br />_
<br />13. EVER IN U.S. ARMED FORCES? Give arse oteervlce if yes. 14a.INFORMAN7•NAME ~
<br />Y
<br />• 4
<br />9/1
<br />3 __
<br />14b. RELATIONSHIP TO DECEDENT
<br /> es
<br />/
<br />957
<br />27/1959
<br />(Yes, no, Drunk.) Betty Beck
<br />~
<br />Wife
<br /> 15. METHpD OF DISPOSITION 15a. EMBALM IONATU i6b. LICENSE N0. 16c. DATE (MO., Day, Yr. )
<br /> rLFBurlal ^Donation ~~~• OCtOber 17, 2009
<br /> ^Cremarion ^Entombment 18d.CEME ERY,CREMATORYORO ERLOCATIpN CITYITOWN STATE
<br /> ^Removal ^Other(Specify) Westlawn Memorial Park Cemetery, Grand Island, NE
<br /> 17a. FUNERAL WOME NAME AND MAILING AppRE55 (Street, City Or TOWn, Stale) 176. Zip Code
<br /> A fe1 Funeral Home, 1123 West Second, Grand Island, NE 68801
<br /> - w; ~:
<br />~ r
<br /> 1& PART L Enter the chain of evante--diseases, injuries, or compllcarlone--lost directly caused the death. 00 NOT enter terminal events such as cardiac arrest, ~ APPROXIMATE INTERVAL
<br /> respiralary arrest, or ventricularii6rillatlon without showing the etiology. p0 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. I
<br /> IMMEDIATE CAUSE: I bn6et to death
<br /> ,~yam ~~ !! ~,A ,' ' 1 ) I ``--ryry/I n
<br />IMMEDIATE CAUSE (Flrlal -~e, -_~ ~ ~
<br />~~ ,
<br />i I ~•-4..v-~l.
<br />~~
<br />_ ,
<br />~
<br />---.
<br />dleea6e pr conditlon resulting DUE TO, OF A5ACONSEOUEHCE OF: [j ~1 onset to death
<br />In death)
<br />~ T r-Q~7 U rn ~7 V I
<br />~.. ~'y~'~ 1
<br />Sequantlanytletcondltlona,if ~) f , 1~.'r~5'~u~~, ~~.~~r {~~`~S~p_.{•,t") ` ~ ~ Y'~
<br />-
<br />~
<br /> any, la9ding tothe cause lleted
<br />DUE TO, OR
<br />A3ACONSEgUENCE OF: i onset ro death
<br />on Ilne a
<br />., ~ .
<br /> EMertlreUNOERLYINGCAUSE
<br />(c) I
<br />
<br />. ~~
<br />(dlaeaeeorln(urythetlnithtad
<br />h
<br />~-f" ---
<br /> _... _.._,.....
<br />t
<br />e ewnta rasulting In death)
<br />DUE TO.OR AS A CONSEQUENCE OF: i onset
<br />LAST
<br /> (d) I
<br /> 18. PAR
<br />T
<br />L OTHER
<br />I
<br />SIGNIFICANTCQNDITIONS-Conditions contributing to the death but not resuglnq In the underlying cause given In PART I. 1g. WA5 MEDIC AMINER
<br /> /
<br />'
<br />~
<br />Q
<br />t
<br />CONTACTE07p
<br />l~O r~ D OR CORONERI
<br />~ ~ ~
<br />-'--." ~
<br />p
<br />^ YES ,q N L~
<br />....
<br />~
<br />:`:.;~-: ............_-
<br />_...
<br />_......_- ..
<br />20. IF FEMALE: 21a.MANNEROFDEATH 21 b. IF TRAN5PORTATIONINJURY 21c.WASANAUTOPSYPERFORMED7
<br />
<br />-+,~ ^ Not pregnant within past year ~Nelurel ^Homicide ^Drlvsr/Operator
<br />~ NO
<br />^Passenger ^ YES
<br />^ Pregnant at lime of death ^ Accldenl^ Pending Inveatigauon
<br />
<br />~~- -
<br />^ Ncl pre nanl, but r0 nent within 42 de a pf death ^ Pedestrian
<br />g P g y OSuicide ^Couldnotbedetermined 21d.WEREAUTOPSYFINDINGSAVAILASLETO
<br /> Nor pregnant, but pregnant 43 days ttl 1 year belore death ^ Other (Specify) CAMPLETE CAUSE OF DEATH?
<br /> Unknown If pregnant within ins past year ^ YE$ ^ NO
<br />_
<br />.~; 22a. PATE OF INJURY (Mc., pay, Vr.) 226 TIME pF INJURY 22c. PLACE OF INJURY-Al home, farm, street, lectory, office building, construction site, etc. (Specify)
<br />m
<br />~~'
<br />{ ~ 22d.INJURYATWORK7 22e.bESCRIBEHOWINJURYOCCURRED
<br /> ^ YES ^ NO
<br /> 221. LOCATION OF INJURY • STREET & NUMBER, APT. ND. CITYAOWN ~_ STATE ~~ ZIP CODE
<br /> 23a. DATE OF pEATH (Mc., Day, Vr.) 24a. DATE SIGNED (Mo., Day, Yr,) 24b.71ME OF DEATH
<br />
<br />
<br />~~ ~
<br />aJ 23b. DATE SIGNED (MO., Day, Vr,) 23c. TIME O~F /QEATH 24c.PRONOUNCED DEAD (Mo., Dey, Yr.) 24d. TIME PRpNOUNCED DEAD
<br />~ m aQ
<br />~ ~~ ~~~ ~
<br /> fifi~ c ~
<br />v
<br />O 7
<br />a ~ ITl
<br />23d. To Iha beat of my knowledge, death occurred at the time, date and place u~ p~p 24e. On the basis of exeminarion andlor Inveetlgetion, in my opinion death occurred et
<br />and due to the cause(s) 6taled
<br />(Si
<br />nat
<br />r
<br />nd Titl
<br />~
<br /> ~ .
<br />g
<br />u
<br />e a
<br />e)
<br />0 ¢¢ p ins time, dale and place and due ro the cause(s) stated. (Signature and Title)
<br /> C ~U~
<br /> 25.DIpTOBACCOUSECONT
<br />R
<br />IGUTETOTHEDEATH7 26e.HASORGANORTISSUEDONATIONeEENCONSIDERED7 266. WAS CONSENTGRANTED7
<br /> a
<br />'
<br />^ YES ^ NO A PROBABLY ^ UNKNOWN ^ YES WND Not Applica6la if 26a Ia NO ^ YES ^ NO
<br /> 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br /> Jennifer Brown M.D. 729 N. Custer Ave. Grand Island NE 68803
<br /> 28a.REGISTRAR'SSIGNATURE 286. DATE FILED BV REGISTRAR (Mo., Day,Yr.)
<br /> ~ • PCT 21 2009
<br />
<br />v
<br />_~
<br />X09
<br />W
<br />HHS~61 11103 (55061)
<br />
|