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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH Al~'IiUMAN S~R,V'ICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA ~~ HEAL7"H AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE WHICH IS THE LEGAL DEPOSITARY FOR VIT,~ r ~\. .5~ Pa, l'; r` ~ ~ t
<br />.~1 '~
<br />DATE OF ISSUANCE ~ J
<br />~, -'*' e ~
<br />07/31 /2009 ~ o i o o i 5 s 3 5T~~~~ ~t fiy,~QPF.R ~ ,
<br />O~~RrTNfFN F•,ME~T~ ~: ~, i _
<br />LINCOLN, NEBRASKA hlUl~i41~X;;S•ER~~i 'P t , c , ' ;~
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVI "i~,E3 a •, `~ °; a . N ~y Og d'1) 6Bz
<br />CERTIFICATE OF DEATM ~ ~- fi~ °?.-r ~-5•..~ ~,
<br /> 1. DECEDENT'S-NAME (First Middle, Last, Suffix) 2. SEX } ~~ ,Y' 9. VA P.,1fEM7H M~"'Oay, Yr.)
<br /> Vera Pauline McIntosh Female ` g ,' t~Gltll~'15;.20d~, `~'
<br /> 4. CITY AND $TA7E pR TERRITORY, OR FpREIGN COUNTRY OF 81RTH 5a. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY' ' B~ DATE;OF,„BIRTH (Mo., Day, Yr.)
<br />-
<br /> (Ymd MOS. DAYS HOURS MINE.
<br /> Wastings, Nebraska 53 November 8, 1955
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 505-$0-1063 H P T ®InpaHant OTHER ^ Nursing HomelLTC ^ Hoeplca Faculty
<br /> 84. FAGILITY•NAME (If not Institution, give street and number) ^ ERlOutpatiant ^ Decedent's Home
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<br /> BryanLGH Medical Center West ^ DOA ^ Other (Specify)
<br />~ Sc. CITY OR TOWN OF DEATH (Include Zlp Code) 8d. COUNTY OF DEATH
<br />p Lincoln 68502 Lancaster
<br />a Ba. RESIDENCE•$TATt: 9b. COUNTY 8c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />~ ed. STREET AND NUMBER 9e. APT. NO. 8f. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 303 E. 16th St, 68803 ®Yes ^ No
<br />~ 10a. MARITAL STATUS AT TIME OF DEATH ®Merrled ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, glue maiden name
<br />!~ ^ Married, but separated ^ Widowed ^ plvorcad ^ Unknown Lpnnle Lee MClntosh
<br /> 11. FATHER'S•NAME (First, Middle, Last, Suffix) 12. MOTHER'$•NAME (First, Middle, Maiden Surname)
<br /> Alvin Wescoat Eunice Kranau
<br />°'
<br />E 13. EVER IN U.S. ARMED FORCES? Glve dates of service If Yes. 14a. INFpRMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />s (Yea, No, or unk.) No Lonnie Lee McIntosh Husband
<br />„Q1n 1S. METHOD OF DISPOSITION 18a. EMBALMERSIGNA7URE 16b. LICENSE N0. 16c. DATE (Mo., Day, YrJ
<br />~ ®Burlal ^ ponatlpn
<br />William M. Clcmanec
<br />1036
<br />July 20, 2009
<br /> ^ Cremation ^ Entombment
<br /> 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> ^ Removal ^ Other (Specify)
<br /> Grand Island City Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HpME NAME AND MAILING ADDRESS (Street, City Or Town, State) 17b. Zlp Gode
<br /> All Faiths Funeral Hpme 2929 S. Locust Street Grand Island Nebraska 68801
<br /> DEATH See instructions an exam es
<br /> 18. PART I. Enter the chain of events--diaaasee, Injuries, Or compllCadpna-that dlnctly cauaad the death. DO NOT enter terminal aVeint such as cardlaG arreffi, :APPROXIMATE INTERVAL
<br /> respiratory arrest, or ventricular fibrillation without ahoWinp the anplpgy. DO NOT ABBREVIATE. Enter Doty one cauN on a Iina. Add atlditlonal Ilnpa If necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final a) Severe Blunt Force Trauma Of Head And Trunk ; Days
<br /> s:a~aaee:condn;~„r.,,:~l;log .... _.__.._.. _.
<br />_..._.
<br />- ---
<br /> In death) ~ --- "'°"~
<br />DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br /> SeQuentlally pat conditions, If b)
<br /> any, leading to the cause Ilatad
<br /> pn une a. pUE T0, OR AS A CpN$EQUENCE OF: onset to death
<br /> Enter iha UNpERLYINC3 CAUSE C)
<br /> (dlaeasa pr Injury that Initiated
<br /> the events resulting In death) p(jE TO, OR A$ A CON$EpIJENCE OF: ~ OnEet tp death
<br /> LAST d)
<br /> 18. PART It. pTHER SIGNIFICANT CONDITIONS-Conditions contrlbuGng to the death but not resulting In the underlying cause pavan In PART I. 18. WAS MEDICAL EXAMINER
<br /> pR CORONER CONTACTED?
<br /> ®YES ©NO
<br />~
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<br />LL 20. IF FEMALE: 21a. MANNER OF DEATH 214. IF TRANSPORTATION INJUR Z1c. WAS AN AUTOPSY PERFORMED?
<br /> ®Npt pregnant within peat year ^ Natural ^ Homicide ^ prlverl0peratpr
<br />®YES ^ Np
<br />tAl Pragnane at [Ime of death
<br />^ ®Accldent ©Pentling Invastlgation ®Pusenger
<br />U ^ Nat propnant, but pregnant wlihln 42 days of death SplrAde Could opt bs determined
<br />© ^ ^ Petlastrlan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />O
<br />P
<br />TE CAUSE OF DEATH?
<br /> ^ Npt pregnant, bul pregnant 47 days tp 1 year before death ^ Otner (Spaclry) M
<br />LE
<br />Tp C
<br /> ^ Unknown If pregnant within the peat year ® YES ^ NO
<br />fl'
<br />E 22a. DATE OF INJURY (Mo., pay, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />$ Jul 3, 2009 08:00 PM Race Track
<br />.Pi 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURREp
<br />° Victim of auto and motorcycle collision
<br />r
<br />- ^YES ®NO
<br /> 22i. LOGATIpN OF INJURY • STREET & NUMBER, APT.NO. CITYI70WN $TA7E ZIP CODE
<br /> Dons hen Race Track, Grand Island Nebraska 68802
<br /> 28a. DATE OF DEATH (Mo., Day, YrJ 24a. DATE SIGNED (Mp., Day, Yr.) 24b. TIME OF DEATH
<br /> ,~ ~ ~' ~ July 30, 2009 06:00 PM
<br /> 23b. DATE SIGNED (Mp., Day, Yr.) 23c. TIME OF DEATH rn ~ 24c. PRONOUNCEp pEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> ~
<br />~ _ ~ ~ ~ ~ Jul 15, 2009 06:00 PM
<br /> _~ p Yid. Tp the bast tlf my knowledge, death occurred at the lima, date antl place
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<br />~ ~ 4e. On the basis of examinatlon endbr InVeatlgatlpn, In my opinion tleath occurred et
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<br /> ~ ~ s Matthias I Okoye, MD JD
<br /> 25. DID TpeACCO USE CONTRI9UTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br /> ^ YES ®NO ^ PRpBABLY ^ UNKNOWN ^YES ®NO Not Applicable If 26a Is NO ^YES ©Np
<br /> IER (PHY I IAN, ) ypa or riot
<br /> Matthias I Okoye, MD JD, 600 S. 70th Street, 3rd Floor, Lincoln, Nebraska, 68510
<br /> 28a. REGISTRAR'S SIGNATURE
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<br />~. ~a~( 28b. PATE FILED BY REGISTRAR (Mo., Day, Yr.)
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<br />30
<br />2009
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