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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF,HEALTH„,~4AR9NblbM( EI~VICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA,S~A EJ~r?,gRT,l1E111~0~ HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE WHICH I5 THE LEGAL DEPOSITORY FOldp~F,A$~ 1~EGORD~.' y .
<br />DATE OF ISSUANCE r/J{r ~ , ~ • '~
<br />~~:V~ frf
<br />07/20/2010 2 010 0 5 2 9 5 STANirEY S, COOPER ~• ' '
<br />ASSISTAIfT~;S~~~T~'+R a1STRA>a ,'
<br />D~P,ARTM~IV d 7`M -A'N~] . A
<br />LINCOLN, NEBRASKA HU~APo! SERVICES ~ ,
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SEF'iSrICL~. • ~r,F /,r i { ? •'•,' :'`~~ • ~,~ -..+,~.. ~ 10 01985
<br />CERTIFICATE OF DEATH ~' f •
<br />,:~ t ~.;
<br /> 1. DECEDENTS•NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE~OF~P-ATH (Mo., Day, Yr.)
<br /> Robert Ra Jewett Male •'JQ '~~; 2010
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last 8lrthday b. UNDER 7 YEAR 5c. UNDER 1 DAY 8. DATE pF BIRTH (MD., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br /> Ralston, Nebraska 80 September 20, 1929
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 607-26-8268 HOSPITAL ^ Inpatlant OTHER ®Nursing Homa/LTC ^ Hosplca Facility
<br /> 8b. FACILITY-NAME (If not Insdtutlon, glue street and number) ^ ER/Outpatient ^ Decedent's Nome
<br />lY
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<br />v Grand Island Veterans Home ^ DpA ^ Other (SpecHy)
<br />~ ec. CITY OR TOWN pF DEATH (Include Zip Cod®) 8d. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br /> 8a. RESIDENCE~TATE 9b. COUNTY 9c. CITY DR TOWN
<br />z Nebraska Hall Grand Island
<br />LL 8d. STREET AND NUMBER e. APT• N0. gf. ZIP CODE 8g. INSIDE CITY LIMITS
<br /> 1108 S. Locust St. 68801 ®Yes ^ NO
<br />
<br />.0 10a. MARITAL STATUS AT TIME OF DEATH ®Married ^ Never Married 10b. NAME OF SPOUSE (Flrat, Mlddlo, Last, Suffix) H wHe, glue maiden name
<br />d
<br />!E
<br />`
<br />^ Married, but separated ^ Widowed ^ Divorced ^ Unknown
<br />Patricia May McKay
<br />m
<br />~ 11. FATHER'S•NAME (First, Mlddlo, Lass, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br /> Llpyd Jewett Mary Dixon
<br />fl•
<br />E 13. EVER IN U.S. ARMED FORCES? Glva dates of service If Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yea, No, nr unk.) Yes 02/12/1951-01/29/1953 Patricia Ma Jewett Wife
<br />a 15. METHOD OF DISPOSITION 18a. EMBALMER-SIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Pay, Yr.)
<br />~ ^ Burial ^ Donation Laurie D
<br />Sheffield 1397 July 20
<br />2010
<br /> . ,
<br /> ® Cremation ^ Emombment "
<br /> 18d. CEMETERY, CREMATORY OR OTHER LOCATION CI7
<br />Y /TOWN STATE
<br /> ^ Removal ^ Other (Speclry)
<br /> Central Nebraska Cremation Services Gibbon Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zlp Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> ee Instructions and exam les
<br /> 19. PART I. Enter the chain of swnts• Nliseawa, Injuries, or compllcatlons4hat diroctly cauwtl the death. DO NOT enter terminal awnta ouch as nrdlac arrest, ; APPROXIMATE INTERVAL
<br /> rospiratory Arrest, or ventricular flbrtllatlan without showing the etlOlopy. DO NOT A88REVIATE. Enter onN one reuse an a Ilna. Add addttlanal Ilnea If naceaaary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final a) Congestive Heart Failure ~ ~ 1 Year
<br /> diseaa or condlUOn rosuttinp
<br /> In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> aevusntlalN pet condklone, i/ b) Restrictive Lung Disease ~ 1 Year
<br /> any, leading to the cause listed
<br /> on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF: ; ansat to death
<br /> Emsrena UNDERLYING CAUSE ~) Venous Ulcers With Cold Injury To Legs ~ 1 Year
<br /> (dIKaH Or Injury that Inttlated
<br /> the averdt reauttlnp In death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br /> LAST d)
<br /> 18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not reaulting In the undertying cause given In PART I. 79. WAS MEDICAL EXAMINER
<br /> Diabetes MBllitus II OR CORONER CONTACTED?
<br /> ^YES ®NO
<br />OC
<br />w 20. IF FEMALE: 21a. MANNER OF DEATH 21 b. IF TRANSPORTATIpN INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />a ^ Noe pregnant wtthln past year ®NaturAl ^ Homldds ©DrlvarlOpsretor
<br /> ^ yES ® NO
<br />~ ^Prepnam at time of death ^ Accident ^ Pandlnp Inresttpatlon ^ Paswnper
<br /> ^ Not Prepnam, but Prepnam wkhln u days of death
<br />[] Suicide ^ Could not be deNrmlrred ^ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />~
<br />~
<br />^ Not prepnaM, but pregnant 4S days to 7 year before death
<br />©Otlwr (Specify) TO COMPLETH CAUSE OF DEATH?
<br />,
<br />,
<br />~ ^ Unknown If pregnant wkhln the pant year ^YES ^ Np
<br />
<br />E 22a. DATE pF INJURY (MO., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, ofnca building, canatructlon alto, etc. (Specly)
<br />
<br /> 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />O
<br />~'
<br />^YES ^ NO
<br /> 22f. LOCATION OF INJURY • STREET 6 NUMBER, APT.NO. CrrYfTpWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (MO., Day, Yr.) 24b. TIME OF DEATH
<br />
<br />A Ji- T~; #010 B
<br /> ~ 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ~
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> a
<br />W ~ Jul 16 2010 10:20 PM }
<br />~ ~
<br />~
<br /> 3d. Ta the beat of my knewbdps, death occurred at the time, data and place
<br />n9turo and Title(
<br />and due to tM cause(s) stated
<br />(Sl ~
<br />2M. On the basis of examination andlor Imreeapatlon, In my oplnbn death occumd at
<br />E ~
<br /> a
<br />x .
<br />p p the tirrq, date and place and due to the wuw(a) stated. (Signature and Thle)
<br />~ ~
<br /> Jennifer King, MD 3
<br /> 25. DID TOBACCO USE CONTRIBUTE 70 THE DEATH? 25a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br /> ® YES ^ NO ^ PROBABLY ^ UNKNOWN ^YES ®NO Not Appllcabla If 28a Ia Np ^YES ^ NO
<br /> I I ype or riot
<br /> Jennifer King, MD, 2300 West Capital Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> July 19, 2010
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