|
<br /> STATE OF NEBRASKA
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEA1_TH AND HU~I~I_SERVICES
<br /> SYSTEM, IT CERTIFIES THE BELOW TO SEA TRUE COPY OF THE'QHIGINAF~ECDRD ON-ft-E WITH
<br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL. STA I~=$~CE(pJ1L};W141CH IS
<br /> THE LEGAL DEPOSITORY FOR VITAL RECORDS. -
<br /> DATE OF ISSUANCE'
<br /> JUL 2 8 2006 VW opaprw
<br /> LINCOLN, NEBRASKA 2 0 1 O(y V 14 Ory J HEALTH rSrarE ~ 1f 4R
<br /> Nfl HUMAN WO S
<br /> STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE A110_SUPPO 27720,
<br /> Amended Jul 28, 2006 CERTIFICATE OF DEATH I 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2-,~EX ` 3. DATE OF DEYY (Mo,. Day, Yr.)
<br /> Howard_ R. Earnest Merle. Jury L~J2006
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Last Birlhday 5b. UNDER 1 YEAR 5c, UNDER 1 DAY 6: DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yr$.) MOS. DAYS HOURSMINS.
<br /> Scotia Nebraska _ 72 January 24, 1934
<br /> 7.,SMIALSECURITY NUMBER Be. PLACE OF DEATH
<br /> 508-40-1968 HOSPITAL: 121 Inpallenl QIHM; ❑ Nursing Home/LTC 0 Hospice Facility
<br /> ~ 81c. FACILITY-NAME (it not institution, give street and number)
<br /> ❑ ER/Oulpallent ❑ Decedent's Home
<br /> ACS
<br /> St. Francis Medical Center ❑ DCA ❑ Other (Specify)
<br /> 8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br /> Grand Island 68803 Hall
<br /> 9a. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
<br /> Nebraska Hall Cairo
<br /> 9d. STREET AND NUMBER 9e, APT. NO 91. ZIP CODE B9• INSIDE CITY LIMITS
<br /> a 307 S. Nubia P.O. Box 334 68824 (3Y YES Q NO
<br /> 10a. MARITAL STATUS AT TIME OF DEATH (k Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Sulllx) If wile, give maiden name.
<br /> ;A? Q Married, but separated ❑ Widowed Q Divorced ❑ Unknown
<br /> Beth Reasland
<br /> 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First,. Middle, Maiden Surname) -
<br /> 4o Guy D Earnest Lucille C. Callaway
<br /> 13. EVER IN U.S. ARMED FORCES? Give dales of service it yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yes, no, orunk.) Yes1/5/55--12/20/ Beth Earnest Wife
<br /> 15. METHOD OF DISPOSITION 16a. EMBAL •51 ATUR~~ 16b. LICENSE NO. 18c. DATE (Mo., Day, Yr. )
<br /> Burial ❑ Donation /Z Ju] ;3 2006
<br /> to
<br /> ❑Cremation ❑Entombment 16d.CEMETERY, CREMATORY ER~LOCATION CITYITOWN STATE
<br /> 1.
<br /> `dr~I 1. ❑ Removal ❑ Other (Specily)
<br /> Mt. Pleasant Cemetery Cairo Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING AODRE5S (Street, Clty or Town, Stale) 17b. Zip Code
<br /> A fel Funeral Home 411 West 11th POBox 126 Wood River, NE 68883
<br /> Ili. PART I. Enter the chain of events--diseases, Injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arres
<br /> IWI~ H
<br /> t, APPROXIMATE INTERVAL
<br /> r( respiratory arrest, or ventricular fibrillation without showing the etlology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines It necessary. I
<br /> IMMEDIATE CAUSE: I onset to death
<br /> _ I
<br /> (a) 1` a ~ rt1 1
<br /> IMMEpIATECAUSE (Final
<br /> disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF: lT I onset to death -
<br /> • In death)
<br /> I
<br /> Sequentially list conditions, It (b)
<br /> I _
<br /> any, leading to the cause listed mm
<br /> on line a. DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br /> .
<br /> Enter the UNDERLYING CAUSE
<br /> °i',r1s~1! (disease or Injury that Initiated (o) 1
<br /> J Mi the events resulting In death) DUE TO, OR ASACONSEQUENCE OF: - - I
<br /> LAST I onset to death
<br /> I
<br /> (d) I
<br /> 18. PART 11. OTHER SIGNIFICANT CON DITIONS-Condilions contributing to the death but not resulting In Ilia underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> _ OR CORONER CONTACTED?
<br /> ` .J i~ l.)...~._ ❑ YES D NO
<br /> - E.
<br /> 20. IF FEMALE: 21a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> '_L2449fufal ❑ Homicide ❑ Driver/OPeralor
<br /> p: 0 Not pregnant within past year ❑ YES Q,J)lB~
<br /> Q Passenger
<br /> " -t ❑ Pregnant at lime of death ❑ Accidenl❑ Pending Investigation
<br /> ` t - ❑ Pedestrian
<br /> ❑ Not pregnant, but pregnant within 42 days of death ❑ guicide Q Could not be determined 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br /> "b Q Not pregnant, but pregnant 43 days to I year before death ❑ Other (Specify) COMPLETE CAUSE OF DEATH?
<br /> ❑ Unknown If pregnant within the pest year ❑ YES (D-116-
<br /> . R.q...
<br /> 8 22a, DATE OF INJURY (Mo,, Day, Yr.) 22b, TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction slle, etc. (Specify)
<br /> in
<br /> 22d. INJURY ATWORK? 229. DESCRIBE HOW INJURY OCCURRED
<br /> ❑ YES Q-NtT
<br /> 22f. LOCATION OF INJURY • STREET A NUMBER, APT. NO. CITY/FOWN l STATE ZIPCOOE
<br /> s Z 23a. DATE OF DEATtil(Mc., Day, Yr.) - 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> a a June 49-, 2006 m
<br /> B
<br /> 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> E° a m a~ rn P0 -July 7, 2QO6 I 1 .10 23d. To the best of my knowledge, death occurred at the time, date and )Place ~ w ~ g 24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br /> H endue dueuse(s) staled. (Signature and Title) o U the lime, dale and place and due to the cause(s) stated. (Signature and Title) r
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. H S OR AN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />
<br /> C1 YES 0 NO ❑ PROBABLY U2-%f9 NOWN ❑ YES 1@'I~Ory Not Applicable if 26a is NO ❑ YES U.-W-
<br /> 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print -
<br /> Taxi Mubin M.D.. 800.N. Alpha. Ave. Grand Island, NE 68803
<br /> 28a. REGISTRAH'S SIGNATURE 28b, DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> JUL 14 2006
<br />
|