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<br /> STATE OF NEBRASKA
<br />
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br /> THE BELOW TO. BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEeARIVFNT,~F HEAL? H AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL I$EC q~.A y. ✓ ti ;
<br /> v
<br /> DATE OF ISSUANCE
<br /> 10/2$/2009 201000917 STANLFYS. C0~72E~ ✓
<br /> ASSISTANT. REGIsTRAR,-
<br /> DEP~1fZTMEN AT~f ANN
<br /> LINCOLN, NEBRASKA HUMAf SER G
<br /> STATE OF NEBRASKA - DE=PARTMENT OF HEALTH AND HUMAN SERVICE S' % 02423
<br /> CERTIFICATE OF DEATH
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX 3.'DATE'OF DEAT (Mo., Day, Yr.)
<br /> George William Worth Male 'pctober 24; 2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a, AGE -Last Birthday b, UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DgYS HOURS MINE.
<br /> Oberlin, Ohio 82 August 10, 1927
<br /> 7. SOCIAL SECURITY NUMBER Ila. PLACE OF DEATH
<br /> 267-22-9014 HOSPITAL Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br /> Bb. FACILITY-NAME (If not Institution, give street and number) ❑ ER/Outpatient ® Decedent's Home
<br /> a
<br /> 1320 N. Hancock Ave. ❑ ODA ❑ Other (Specify)
<br /> LU 8c. CITY OR TOWN OF DEATH (include zip Code) 8d. COUNTY OF DEATH
<br /> 8 Grand Island 68803 Hall
<br /> J 9a. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
<br /> UJ Nebraska Hall Grand Island
<br /> LL 9d. STREET AND NUMBER 9e. APT. NO. 9f, ZIP CODE 9g, INSIDE CITY LIMITS
<br /> a 1320 N. Hancock Ave. 68803 2 YES ❑ No
<br /> .0 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br /> d
<br /> ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Janet Ruth Trueblood
<br /> `m
<br /> 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br /> James Harry Worth Ellen Beckwith
<br /> a 13. EVER IN U,S, ARMED FORCES? Give dates of service It Yes, 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br /> E
<br /> (Yes, No, or Unk.) Yes 03/28/1945-01131/1969 Janet Ruth Worth Wife
<br /> 15. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br /> F° ❑ Burial ❑ Donation Daniel D Naranjo 1071 October 27, 2009
<br /> ® Cremation ❑ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br /> ❑ Removal ❑ Other (Specify)
<br /> Central Nebraska Cremation Services Gibbon Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> AUSE OF A (See Instructions and exam lee
<br /> 1e. PART I. Enter the char of events--diseases, Injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, ) APPROXIMATE INTERVAL
<br /> respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines 11 necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final a) ACUTE MONOCYTIC LEUKEMIA ONE MONTH
<br /> disease or condition resulting
<br /> in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Sequentially list conditions, if b) MYELODYSPLASIA SYNDROME E ONE YEAR
<br /> any, leading to the cause listed
<br /> an line a.
<br /> DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE C)
<br /> (disease or injury that initiated
<br /> the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF; onset to death
<br /> LAST dl
<br /> 16. PART 11, OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given In PART 1. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> a: ❑ YES ® NO
<br /> 20. IF FEMALE; 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> H ❑ Not pregnant within past year [Ej Natural ❑ Homicide ❑ Driver/operator
<br /> !Y
<br /> U E] Pregnant at time of death L] Accident © Pending Investigation El Passenger YES ® NO
<br /> ❑ Not pregnant, but pregnant within 42 days Of death © Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br /> ❑ Suicide ❑ Could not be determined
<br /> ❑ Not pregnant, but pregnant 43 days to 1 year before death other (specify) TO COMPLETE CAUSE OF DEATH?
<br /> © Unknown If pregnant within the past year ❑ YES ❑ NO
<br /> E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify)
<br /> t7
<br /> u
<br /> a 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br /> F
<br /> ❑ YES ❑ NO
<br /> 22f. LOCATION OF INJURY - STREET & NUMBER, APT-NO. CITYITOWN STATE ZIP CODE
<br /> 23a. DATES OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> . W October 24, 2009 ~g~
<br /> a Y 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ° 24c, PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> g l October 26, 2009 05:05 PM a a
<br /> N
<br /> se. To the beat of my knowledge, death occurred at the time, data and place
<br /> o and due to the cause(s) stated. (Signature and Title) z 3 24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br /> ti m 008 the time, data and place and due to the cause(s) stated. (Signature and Title)
<br /> Jane A. McDonald, MD 0 ~s
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br /> . ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO Not Applicable if 26a Is NO
<br /> ❑ YES ❑ NO
<br /> 27. ME, TITLE ADDRESS PHYSICIAN ATTORNEY) (Type or r nt)
<br /> Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> J6 I October 26, 2009 J
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