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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL
<br />THE BELOW TO BE A TRUE COPY OF THE ORI IAL REECORD ON FILE WITH THE NEB
<br />HUMAN SERVICES, VITAL RECORD F S THE LEGAL DEPOSITORY FO ~A
<br />DATE OF ISSUANCE ~~ ~ ~~~
<br />01 20 >~ r ~
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<br />09/21/2009 Boo LEir '~tSl~
<br />LINCOLN, NEBRASKA Coupln~(yClerk
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER C~:
<br />CERTIFICATE OF DEATH `'-~
<br />RVICES, IT CERTIFIES
<br />7F+J-dEALTH AND
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<br /> 1. pECEDENT'S-NAME (First, Middle, Last, Suffix) 2, SEX ~ pEAT~o., Day, Yr.)
<br /> James Allan Freer Male Septemirer"6, 2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE pF BIRTH (Mo., Day, Yr.)
<br /> IYrs•) MpS. DAYS HOURS MINS.
<br /> Furnas County, Nebraska 75 May 2, 1934
<br /> 7. SOCIAL SECURITY NUMBf:R ea. PLACE OF DEATH
<br /> 505-40-6717 HOSPITAL ®Inpatlent OTHER ^ Nursing HomalLTC ©Hosplce Facility
<br /> eb. FAGILITY•NAME (H not Inatltutlon, glue street and number) ^ ERfOutpatlent ^ Decedent's Homa
<br />
<br />
<br />U Saint Francis Medical Center ^ DOA ^ Other (specify)
<br />w 8c. CITY OR TOWN OF DEATH (Include Zip Code) Sd. COUNTY OF pEATH
<br />o Grand Island 68803 Hall
<br />J 9a. RESIDENCE•S7ATE 9b. COUNTY 9c. CITY OR TOWN
<br /> Nebraska Hall Grand Island
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<br />9d. STREET AND NUMBER
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />9g. INSIDE CITY LIMITS
<br />~, 3127 Woodrid a Blvd 68801 ®Yes ^ No
<br /> 70a. MARITAL STATUS AT TIME pF DEATH ®Married ^ Never Married tgb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, glue maiden name
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<br />d ©Married, but separated ^ Widowed ^ Divorced ^ Unknown Shirley Janet Strickland
<br />~ 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br />~ Ray Freer Verna Bose
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<br />E 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP Tp DECEDENT
<br />~ (Yes, No, Or Unk.) NO Shlfle Janet Freer Wife
<br />a 75. METHOD OF DISPOSITION 78a. EMBALMER-SIGNATURE 186. LICENSE Np. 76c. DATE (MV., Day, Yr.)
<br />H ®Burial ^ Donation
<br />Daniel D Naranjo
<br />1071
<br />September 12
<br />2009
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<br /> ^ Grematlan ^ Entombment
<br /> 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> ^ Removal ^ Other (Specify)
<br /> Grand Island City Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, State) 17b. Zlp Code
<br /> All Faiths Funeral Home, 2929 5. Locust Street, Grand Island, Nebraska 68801
<br /> AUSE F DEA W See instructions and exam les
<br /> 18. PART 1. Enter the chain of events-diseases, injuries, or complica[lenadhat directly caused the death. DO Np7 enter terminal evenle each ai cardiac arrea6 ; APPROXIMATE INTERVAL
<br /> respiratory arrest, or ventricular flbrlllatlon without showing the atlolagy. DO NOT ABBREVIATE. Enter only one cause do a Ilna. Add additional lines If necessary.
<br /> IMMEDIATE CAUSE: 01188t t0 death
<br /> IMMEDIATE CAl1SE (Final a) Acute Renal Failure ;Days
<br /> disease or condition resulting
<br /> In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> SaqueMlally Iiat candltions, If b) Metastatic Renal Cell Carcinoma ;Months
<br /> any, leading tc the cause listed
<br /> on une a. DUE 70, OR AS A CONSEQUENCE OF: ; vnaet tv death
<br /> Enter the 4NDERLYING CAUSE r')
<br /> (tliwaie or IrlJury gnat Initiated
<br /> the aveMa resulting In death) DUE TO, OR AS A CONSEQUENCE OF: ~ onset to death
<br /> LAST d)
<br /> 18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contrlbuting to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> Atrial Fibrillation, Bullous Pemphigoid, Hypercalcemia Of Malignancy OR CORONER CONTACTED?
<br /> ^YES ®NO
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<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> ^ Not pregnatd wthln past year ®Naturel ^ Homicide ~ Ddverlvperetor
<br /> ^ YES ® NO
<br />V ^ Pregnant at dma of death ~ ACddent ^ Pending Investigation ^ Passenger
<br /> ^ Not pregnan6 but pregnant wlthln 42 days of death guiclda Could not ba determined
<br />© ^ ^ Petlestrlan 21 d. WERE AUTOPSY FINDINGS AVAILg9LE:
<br /> © Not pregnant, but pregnant 49 days to 1 year before death ~ Other (5paciTy) TO COMPLETE CAUSE OF pFr4TW9
<br /> ^ llnknawn H pregnant wlthln the past year ^YES ^ NO
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<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, afflce building, construction site, etc. (Speclty)
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<br />YS' 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
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<br />^ YE5 ^ NO
<br /> 22f, LOCATION OF INJURY -STREET & NUMBER, APT.NO. CITY/1'OWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (MO., Day, Yr.) 246. TIME OF pFJ1TH
<br /> ~ ~ September 6, 2009 ~ ~
<br /> Y 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ~ ~ ~ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> g }~ -~ Se tember 10, 2009 12:05 PM ~
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<br />death occurred at the time
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<br />© 24e. on the bails of examination dndlor Inveetlgatldn, In my opinion death occurred at
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<br />o the lima, data and place, and due to the rausajs) stated. (51gna[ure and TI[le)
<br /> ~ ~ Jay C. Anderson, MD `" $ o
<br /> 25. Dlp TOBACCO USE CONTRiBUTfW TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br /> ^ YES ®NO ^ PROBABLY ^ UNKNOWN ^YES ®NO Not Applicable if 2ga is NO ^YES ^ NO
<br /> I A AD E IFI AN P I IAN NTY A RN Y) Type or riot)
<br /> Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE /~ 28b. PATE FILEp f3Y REGISTRAR (MO•, pay, Yr.)
<br /> ~ September 10, 2009
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