|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL'IY'(.;~~lU~Al~'~,~'t;IrIC~S; IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA~ICA~`('~~P.AI7TM~IVT A~` H,~ILTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY Pf7R VIT.,xti~~RF~LIRE7,Sr7 ~' • ` , w
<br />DATE OF ISSUANCE "~+* ~`!~.
<br />STAItlL"EY, GC~7PJ~R f ,
<br />12/23/2009 • R~ ASS~S~A"N~151<A7~ RL~~1`STR.4IZ ;;-
<br />2 0~ 0 0 0 1 s J DEP,+4RTl`~EN1;,OJ~'1.1'~ArLTl-l ANA ,
<br />LINCOLN, NEBRASKA HUMAIV,'SL'"I,2'6~I,G"ES . •'.;~ ~. • `
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN $ERVICE3 09 03003
<br />CERTIFICATE OF DEATH ' ~~~ , .
<br /> 1. pECEpENT'S•NAME (First, Middle, Last, SufFlx) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br /> Ra mond Vester Magwire Male December 13, 2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 pAY e. PATE OF BIRTH (Mo., Day, Yr.)
<br /> 1Y-s•) MOS, DAYS HOURS MINE.
<br /> Tilden, Nebraska 89 November 9, 1920
<br /> 7. SOCIAL SECURITY NUMBER Ba. PLACE OF pEATH
<br /> 506-16-7013 HOSPITAL ^ Inpatient ~,TJiEB ^ Nuning Home/LTC ^ Hosplca Facility
<br /> Bb. FACILITY•NAME pf net Instltutlon, give street and number) ^ ER/Outpatlant ®Dacedant's Home
<br />
<br />0
<br />U 1736 Doreen 5t. ^ DoA ^ Other (Specify)
<br />~ 8c. CITY OR TOWN OF DEATH (Include Zip Code- 8d. COUNTY OF DEATH
<br />S Grand Island 68803 Hall
<br /> s>a. RESIDENCE-STATE eb. COUNTY 9c. CITY OR TOWN
<br />~ _Atebrzska ~~-Mall E3rand~sland - -_. _. ~,.~~-..
<br />7 9d. STREET AND NUMBER .APT. NO. 9F. ZIP CODE 9p. INSIDE CITY LIMITS
<br />~, 1736 Doreen St. 68803 ®YES ^ No
<br /> 1tla. MARITAL STATUS AT TIME OF DEATH ®Marrlad ^ Never Marrlad 10b. NAME OF SPOUSE (Pint, Middle, Last, Suffix) H wHe, glue maiden name
<br /> ^ Marrlad, but separated ^ Widowed ^ pivorcad ^ Unknown Margaret Ruth Cram
<br /> 11. FATHER'S-NAME (Pint, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br /> Vester Hayes Magwire Alma Maven
<br />a
<br />E 19. EVER IN Us. ARMED FORCES? Give dates of service K Yae. 14a. INFORMANT•NAME 14b. RELATIONSHIP Tp DECEDENT
<br />$ (Yea, No, or unk.) Yes 10/10/1942-02/20/1946 Margaret Ma wire Wife
<br />,~ 15. METHpp pF DISPpSITIpN 18a. EMBALMERSIGNATURE 76b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />N ®aurial ^ Donation
<br />Laurie D
<br />Sheffield
<br />1397
<br />December 16
<br />2009
<br /> . ,
<br /> ^ cremation ^ Entombment
<br /> 16d. CEMETERY, GREMATDRY pR DTHER LOCATION CITY! TOWN STATE
<br /> ^ Removal ^ Other (Specify)
<br /> Grand Island City Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HpME NAME ANp MAILING ADDRESS (Street, Clty or Town, State) 17b. Zlp Code
<br /> All Faiths Funeral HDme, 2929 S. LDCUSt Street, Grand Island, Nebraska 68801
<br /> A ee Instructipns an exam es
<br /> 16. PART I. Enter iha p~JD•QL@yp,gl!•Aliaaaaa, inJurlei, or compllCalloN•tbat directly auwd the death. DO NOT aMar terminal weMn such as cardiac arrant, APPROXIMATE INTERVAL
<br /> naplratory arrail, or yantncular flbrlllation without showing the etiology. DO NDTA88REVIATE. Erder any orw nuw on ^ Ilne. Add additional Ilnen If necenaary.
<br /> IMMEDIATE CAUSE: onset t0 death
<br /> IMMEDIATE CAIJ$E (Flndl a)ASpiration Pneumonia 2 Weeks
<br /> dlteata Or cdndllion resulting
<br /> In death) DVE Tp, OR AS A CONSEQUENCE OF: ) Onset t0 death
<br /> sequantlaly eat conditions, H b) Dementia :Years
<br /> any, leading t0 iha Cause Meted
<br /> on Iinv a.
<br />DUE TO, OR A5 A CONSEQUENCE OF: onset to death
<br /> Enter tlw UNDERLYING tiAll$E C)
<br /> (dlaesp dr Injury that Inltlarod
<br /> the events roaultlnp In daathl DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> LAST d) _.
<br /> 18. PART IL OTHER SIGNIFICANT COND1TIpNS-Condltlong conVibutlny to the death but not resulting In the underlying cause given In PART I. 18. WA5 MEDICAL EXAMINER
<br /> OR CORONER CpNTACTED?
<br /> ® YES ^ Np
<br />Q.r
<br />W 20. IF FEMALE: 27a. MANNER OF pEATH 21b. IF TRANSPORTATION INJURY 21 c. WAS AN AUTpPSY PERFpRMED?
<br />~ ^ Not prepnam wlthln peat year ®Natunl ©Homlclde ^ Drlwr/operator ©YES ® Np
<br />~ ^ Pregnant at time of death ^ Accident ^ Pending investigation ^ Pannenper
<br /> © Nat pregnant, but pregnant wlthln 4Z days dT death suicide Could not IH determined
<br />^ ^ ^ Padeatdan 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />C
<br />O
<br /> ^ Not pregnant, but pregnant 4a dayr td 1 year tnfore death ^ Olhar (Specify) TO COMPLETE
<br />F DEATH?
<br />AUSE
<br />D
<br />~
<br />^ Unknown II propnant wlthln the pant year
<br />^YES ^ NO
<br />°' 22a. pATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OFINJURY-At home, farm, street, factory, ofFlce building, construction alto, etc. (Specify)
<br />
<br />Sr 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />~
<br />^ VES ^ NO
<br /> 22T. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br /> 23a. PATE OF pEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Pay, Yr.) 24b. TIME pF DEATH
<br /> ~' W December 13, 2009 S
<br />~
<br /> } 236. DATE SIGNED (Mo., Day, Yr.) 23c. TIME pF DEATH _
<br />~ ~ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED pEAD
<br /> o December 22, 2009 09:15 AM
<br />» ~
<br /> Sd. To the ban of my knowledge, daNh occurred at the lima, date and place
<br />$ and due to the cause(s) smrod
<br />(Si
<br />nature and TNIe) $
<br />$ ~ ~ 19e. pre the heals or examinatlon andlar Invaatlpatlon, In my opinion death occurred at
<br />n
<br />d Tlti
<br />th
<br />ti
<br />d
<br />t
<br />d
<br />l
<br />d d
<br />t
<br />tb
<br />t
<br />t
<br />d
<br />(Si
<br />t
<br />)
<br /> .
<br />g e
<br />me,
<br />a
<br />e an
<br />p
<br />ace an
<br />ue
<br />o
<br />a cause(s) s
<br />a
<br />e
<br />.
<br />g
<br />a
<br />ure an
<br />e
<br /> ~ Travis S. Hageman, MD ~ ~ s
<br /> 25. DID.TDF3A000 USE GDNTRIeUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREp7 286. WAS CONSENT GRANTED?
<br />
<br />^ YES ^ NO ^ PROBABLY ®UNKNOWN .. .
<br />^YES ®NO Nat Applicable H 28a Is NO ^YES ^ NO
<br /> ype or r n
<br /> Travis S. Hageman, MD, 729 Nprth Custer Avenue, Grand Island, Nebraska, 68603
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED 8Y REGISTRAR (Mo., Day, Yr.)
<br /> December 23, 2009
<br />
|