|
STATE OF NEBRASKA
<br />~ WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTf'h~l' r~S,~RV7CE5, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR.ASK~,~AR'M1~T~ MEA~;,TM AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICM IS THE LEGAL DEPOSITORY FOR 1/~AL• RE•~D D~. ~ ~
<br />~, ,. glw ~,~ ~~.
<br />DATE OF ISSUANCE ,~~,~ ~~,,
<br />~~~ ~~
<br />05/18/2010 2 010 4 4 9 3 6 ~~"~ p~ A,~'~r,~~-R
<br />L~~~,AR7'MENT ~f flF.,14C,'r~7; r~ln'ID.^'
<br />LINCOLN, NEBRASKA F717N~AN.S,~~'tt?~,~G~S`~ , t., ;' r,,' .
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SEI~lIG'~$ •' ~~ ~~~ ~~Cr%; •~' - ^~ ra . ~ Q 01340
<br />CERTIFICATE OF DEATH ~+'; ~,,;',~,~.' ~J`=~~'' ~'"'
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX
<br />. ~ ASE Q~ DEATH (Mo., Day, Yr.)
<br /> Onda Ella Scott Female
<br />~ " RA~y"10, 2010
<br /> 4, CITY ANp STATE pR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. PAYS HOURS MINE.
<br /> Boelus, Nebraska 95 Jul 26, 1914
<br /> 7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br /> 506-64-3892 ~iQ~PI7L-L ®Inpatlent ~8 ^ Nuraing HomelLTC ^ Ho;plce Facility
<br /> Bb. FACILITY-NAME (H not Instltutlon, glue;treat and number) ^ ER/Outpatlent ^ Decedent's Home
<br />
<br /> Mary Lanning Memorial Hospital ^ DoA ^ Other(SpecHy)
<br />~ 8c. CITY pR TOWN OF DEATH (Include Zlp Code) ed. COUNTY DF DEATH
<br />o Hastings 68901 Adams
<br /> 9a. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
<br />w
<br />z Nebraska Hall Presser
<br />LL 9d. STREET AND NUMBER e. APT. NO. 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />;; 11968 West Platte River Road 68883 ^ res ®No
<br />~ iDa. MARITAL STATUS AT TIME OF DEATH ^ Married ^ Never Married 186. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden Hams
<br /> ^ Married, but separated ®Wldowed ^ Divorced ©Unknown
<br />d
<br /> 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br />~ Royal Bishop Onda Unknown
<br />°'
<br />E 19. EVER IN U.S. ARMED FORCES? Give dates of service H Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEpENT
<br />$ (Yea, No, or Unk.) NO Joe Lille Son
<br />°~ 15. METHOD OF DISPOSITION 18a. EMBALMER-SIGNATURE 18b. LICENSE NO. 78c. PATE (MO., Day, Yr.)
<br />F? ®Burlal ^ Donation
<br />Derek Apfel
<br />1240
<br />May 14
<br />2010
<br /> ,
<br /> ^ Cremation ^ Entombment
<br /> 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> ^ Removal ^ Other (Specify)
<br /> Juniata Cemetery Juniata Nebraska
<br /> 17a. FUNERAL HDME NAME AND MAILING ADDRESS (Street, Clty or TOWn, Stets) 176. Zlp Code
<br /> Apfel Funeral Home, 411 W 11th St., Box 126, Wood River, Nebraska 68883
<br /> CAU E F T ee nstruct one an exam es
<br /> fa. PART I. Enror the chain o[ enema--dlaeaeaa, InJwlea, or compungpna-that dlroctly caused the death. DO NOT enter terminal avant such as wrmac arrert, :APPROXIMATE INTERVAL
<br /> roapirotory amst, or vanMcular gbdlla[Ipn without showing the a[Iplogy. Dp NOT ABBREVIATE. Emer Only One cause On a Ilse. Adtl atltlttlonal Ilnee I} necateary.
<br /> IMMEDIATE CAUSE: ; onset to death
<br /> IMMEDIATE CAUSE (Final al Cardiopulmonary Arrest ; 10 Min
<br /> disease or conelnon roauttinq
<br />- In death) pUE TO, UR A$ k GONBEDUENCk OF: _ - • ' Onset to death
<br /> Sequentially uat condhions, if b) Cachexia
<br /> any, leading to the cauw listed
<br /> on Ilne a.
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Entartha UNDERLYING CAUSE G) Advanced Age
<br /> (disease or InJury that Initlarod
<br /> the events rosuttlnq In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> tAST d)
<br /> 18. PART II.OTHER SIGNIFICANT CONDITIONS~ondltlons contrl6uting tp the death but not resulting In the underlying cause gWan In PART I. 19. WAS MEDICAL EXAMINER
<br /> Esophageal Obstruction OR CORONER CONTACTED?
<br /> ^ YES ®NO
<br />~
<br />W 28. IF FEMALE: 21 a. MANNER OF DEATW 21 b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> ^ Not pregnant wlthln past year ®Naturol ^ HomiCida ^ Driver/Operator
<br /> ^ YES ®Np
<br />~ ^ Prognant at time of death ©Accltlem ^ Pendlnq Imaatlgatlpn ^ Passenger
<br />
<br />~+ ^ Npt prognant, but pregnant wlthln 42 days of death
<br />^ Suldtle ^ Could not 4e dstennineo ^ Psdsatdan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />
<br />,
<br />^ Not pregnant, but prognant 49 days tp 7 year bafpro death
<br />^ ether ISneclryi 7p COMPLETE GAUSE pF DEATH?
<br />~ ^Unknown If prognant wlthln the pan year ^ YES ^ NO
<br />~ 22a. DATE OF INJURY (Mo., Day, Yr.) 226. TIME OF INJURY 22c. PLACE pF INJURY•At home, farm, street, factory, office building, wnatructlon alto, etc. (Spec Hy)
<br />
<br />~' 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY pGGl1RRED
<br />0
<br />f"
<br />^ YES ^ NO
<br /> 22f. LOCATION OF INJURY -STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br /> 2Sa. DATE OF DEATH (Mo., pay, Yr.)
<br />~
<br />~ 24a. DATE 81GNED (Mq., Day, Yr.) 246, TIME pF DfSATH
<br /> May 10, 2010 3•
<br />~
<br /> 2
<br />h
<br />DATE SIGNED
<br />D
<br />Y 2S
<br />TIME OF
<br />EATH ~ 24
<br />PRON
<br />NCED DEAD
<br />M
<br />D
<br />Y 4
<br />TIM
<br /> r,
<br />3
<br />.
<br />(Mo.,
<br />ay,
<br />r.) c.
<br />D
<br />_. _ ~ (
<br />p.,
<br />OU
<br />C.
<br />ay,
<br />r.)
<br />'~ 2
<br />d.
<br />E PRONOUNCED DEAD
<br /> ~ ~ z Ma 11, 2010 03:00 AM ~ _
<br />"'
<br /> 8 ~ o
<br />9d. To the beat of my knowleaga, death occurroa at the time, daW and place
<br />and pus to the Causelsl stated
<br />(Si
<br />nature and Tkle)
<br />o ~ w ~ 0
<br />~
<br />p 34e. On the bask of eaaminaHon anNor Inveatlpatlon, in my opinion death Occurred at
<br /> .
<br />g
<br />i5 ~ the tines, date and place and due to the uuw(a) stated. (8lgnaturo and Title)
<br /> ~ Richard French, MD g `o
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIpBRED7 28b. WAS CONSENT GRANTED?
<br /> ^ YES ®NO ^ PROBABLY ^ UNKNOWN ^ YES ®NO Not Appllca6la If 28a I; NO ^ YES ^ NO
<br /> ype or r
<br /> Richard French, MD, 2115 N Kansas Avenue, Hastings, Nebraska, 68901
<br /> 28a. REGISTRAR'S SIGNATURE 286. DATE FILED 8Y REGISTRAR (MO., Day, Yr.)
<br /> May 14, 2010
<br />
|