|
l
<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL pF THE NEBRASKA DEPARTMENT OF'HEALTM AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA ~iY~'~I~~IYT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOr~~'~ D~,~~~ ;~ .
<br />~~~- ~
<br />DATE OF ISSUANCE .~ y . , ~ „~ ,~r~
<br />~'S~I/VLEY S. GQQpER •. Y" «r% '
<br />AUG ~„ ~ '~ :~,~~TST ., T,~TATE REGISTZtA~',
<br />~': D~PART/~-F OL~'r;HI~ALTH:,~yC1..:
<br />LINCOLN, NEBRASKA ~ 41 O 0 ~ iO 1 F•~W,4N ER111~E~ "-~ =•
<br />STATE OFNEBRASKA - DEF'AfaTMENT OF HEALTH AND HUMAN SERVICES FINY\I1~C~ AN?~/~l`.fFF'FIO `\ '"~•
<br />CERTIFICATE OF DEATH ;. ,.~•~ ~ ?_ 7 9 3 3
<br /> 1. DECEDENT'S-NAME (First, Middle, Lest, Sulfix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br /> Donald Hart Simpson Male July 26, 2008
<br /> 4. CITY ANp STATE OR TERRITORY, OR FOREIGN COUNTRY OF 81RTH 5a. ApE•Last Birthday 5b, UNDER 1 YEAR 5c. UNDER 1 DAY 8. pA7E OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINE.
<br /> Rural tree]-zy County, NE
<br />~ 78 .1a.nuary 15, 193Q
<br /> 7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br /> 507-38-5274 HOSPITAL: ^Inpetlent 4TNE9;' ^NuraingHomelLTC ^HospiceFacility
<br /> 86. FACILITY•NAME (If not Institution, give street and number)
<br />^ ER/Outpatient ~ pecedent's Home
<br /> Home: 105 East 12th
<br />
<br />_ ^ ~, ^Other(Speclty)
<br /> Bc. CITY DRTDWN OF DEATH (Include Zip Code) Bd. COUNTY OF DEATH
<br /> Wood River 68883 Ha11
<br /> 8a. RESIDENCE-STATE Bb. COUNTY 9c. CITY OR TOWN
<br /> Nebraska Hall Wood River
<br /> gd. STREETANDNUMBER Be. APT. NO 81. ZIP CODE 8g. INSIDE CITY LIMITS
<br />b„ 105 East 12th _ _ 68883 ~ YES ^ ND
<br /> 1oa. MARITAL STATUS AT TIME OF pEATH ~ Married ^ Never Married _
<br />10b. NAME OF SPOUSE (First, Middle, Last, Sufllx) If wife, give maiden name.
<br />off;
<br />~'~'~
<br />^ Mewled, but separated ^ Widowed ^ Divorced ^ Unknown
<br /> Maxine Zulkoski
<br />
<br />~ 11. FATHER'S•NAME (First, Middle, Lest, Suftix) 12. MpTHER'S•NAME (First, Mlddls, Maiden Surname)
<br />• Hart Simpson__ Anna Henke
<br />•~';~ ~. 13. EvVER IN U.SR. ARMED FORCES? Give date of service If yes, i4a. INFORMANT•NAME ~
<br />'/7/1947 5/261950
<br />~
<br />G 14b. RELATIONSHIP TO DECEDENT
<br /> (Yee;nS,b
<br />r
<br />nk.j
<br />~ Maxine Simpson
<br />_ Wi£e
<br /> _ _
<br />15. METH00 OF DISPOSITION 18a. EM M •SIGNATURE
<br />t8b. LICENSE
<br />N
<br />0. 18c. DATE (Mo., pay, Yr. )
<br />
<br />' tt
<br />//
<br />~,Budal ^Donetion _~ ~ 7U JUly 30, 2008
<br />.~
<br />.~h ^Cremation ^Entombmenl 18d.CEMETERY,CREMATO OT RLOCATION CITY/TOWN STATE
<br /> ^Remaval ^Otner(Speclfy) Westlawn Memorial Park Cemetery Gra;tld Island, NE
<br />I
<br /> 17a. FUNERAL HOME NAME AND MAILd:G AbbRE3S (Street, Dlty orTown, Stets) 17b. Zip Coda
<br />`~r;, Ap£el Funeral Home, 1123 West Second Grand Island, NE. 68801
<br /> '
<br /> 18. PART I. Enter the chain of events-•dlseases, Injuries, or complications••ihat directly caused the death. bq NpT enter terminal events Such es Cardiac arrest, it APPROXIMATE INTERVAL
<br /> respiratory arrest, or venirlcular librillatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary. I
<br />i'", IMMEDIATE CAUSE' I onset to death
<br />I
<br /> IMMEDIATECAUSE(Final (a) heart failure _ 'immediate
<br /> dlaeasearcondifionreaulting DUE TO, ORASACONSEQUENCEOF: I onset to death
<br /> In death)
<br /> Sequentially Iln conditions, If (b) I
<br /> eny,leadingtothecauaelisted pUETO,ORASACONSEQUENCEpF: I ansettodeelh
<br /> on Ilna a.
<br /> I
<br />EntwlhsUNpERLYINGCAU5E
<br /> (dlceaaeorlnJurythatinitiated (c) I
<br />~i ' the avards reauging In death) ~~_....._._.-- ._.... .,.. ..-......_ -....-.._.-. IT_....
<br />DUE T0, OR AS A CONSEQUENCE OF: I onset to death
<br /> L{18T
<br />I
<br /> (d) I
<br />'~ ~ ` 18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but ndt resulting in the underlying cause given in PART I. 18. WAS MEDICAL EXAMIN
<br />ER
<br />- OR CORONER CONTACTEp7
<br /> X7 YES ^ NO
<br />•~~
<br />;w
<br />~
<br />w~w
<br />'..
<br />~' 2tl.IFFEMALE: __~ 21a.MANNEROFpEATH 2tb.IFTRANSPORTATIONINJURY 21c.WASANAUTOPSYPERFORMED?
<br />
<br />^ Not pregnant within pest year ~) Natural ^ Homicide ^ Driver/pperator
<br />©Pregnam at lime of deatn ^ Accident^ Pending Investlgatlon ^ Passenger ^ YES ~ NO
<br />.:V ^ Pedestrian
<br />^ Not pregnam, butpregnanl within 42 days of death ^ Sulclde ^ Could not be determined 21d. WERE AUTOPSY FINDINGS AVAILABLETO
<br /> ^ Not re nan6 but re nant 43 da s to 1 ear before death ^ Other (Specify)
<br />P 9 p 9 Y Y COMPLETECAUSE
<br />OFDEATH7
<br />~~~. y
<br />^ Unknown if pregnant Within the past gear __ _ ^ YES LI ND ~
<br />
<br />y °
<br />n ?
<br />22a. DATE OF INJURY Mo., De Yr. 22b TIME pF IN building, construction site, etc (Specify)
<br />JURY 22c. PLACE pP INJURY-At home, term, street, factory office
<br />1 Y, 1 ~
<br />m
<br />
<br />'r' ... ..
<br />__._
<br />_.___
<br />22d.INJURYATWORK7 22e.DESCRIBEHOwINJURY000URRED
<br />
<br />"
<br />: ^ YE5 ^ ND
<br />n
<br /> 22f, LOCATION OF INJURY • STREET & NUMBER, APT. N0. CITY/tOWN STATE ZIP CODE
<br />
<br />~ 23a. DATE OF DEATH (Mo., Dey, Yr.) } 24a. DATE SIGNED (Mo.. Day,Yr.) 24b.TIME OF DEATH
<br />~
<br />~ $ ~ Au u5t 72008
<br />5:00
<br />~'~
<br />am
<br /> ~r __
<br />.. _
<br />~.-___..._
<br />238. DATESIGNEb(Mo.,Day,Yr.) 23c.TIMEOFDEATH ~~~ 24c.PRpNOUNCEDDEAD(Mo.,Dey,Yr.) 24d.TIMEPRONOUNCEDDEAD
<br /> ~;,~ ~ ~~~o Jul 2fi 2008 7:D0 m
<br /> .0 23d. To the best of my knowledge, death occurred at the time, date and place ~ ual ~ 24e. On the basis of examination and/or inveatigallon, In my opinion death occurred at
<br />d d
<br />t
<br />th
<br /> ~ ~ an
<br />ue
<br />o
<br />e cause(s) stated. (Signature end Title) • o ~ U e time, date and a and d to the c use(s) stated. (Signature and Title) ~
<br /> a ~ deputy Hdll
<br />U `
<br /> o
<br /> 25. DIb70BA000 USE CONTRIBUTE70THE DEATH? 28e. HAS ORGAN DR TISSUE DONATION BEEN CONSIDERS ~ 28b. WAS CONSENT GRANTED?
<br /> C] YES ^ NO ^ PROBABLY ~ UNKNOWN
<br />_ ....
<br />~~~~~- -~- - ^YE5 1;1 NO Nol Appllcaele if 26a is Nq ^YE5 1~1 NO
<br />_
<br />--~-
<br />~
<br /> .
<br />. -
<br />27. NAME, TITLE ANDADORE53
<br />-~'R'-_~
<br />pP CERTIFIER (PHYSICIAN, CORONER'3 PHYSICIAN OR COUNTY ATTORNEY) (Type or print)
<br /> Robert J. Cashoi1i, Deputy Hall County Attorney, 231 S. Locust St., Grand Island, NE f
<br />28a. REGISTRAR'S SIGNATURE /jam
<br />llr"Ir8]
<br />,~
<br />286. DATE FILED BY REGISTRAR (Mo., Dey, Yr.)
<br />AuG x ~ zoos
<br />18801
<br />
|