|
'~ STATE OF NEBRASKA
<br />S. y
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH,A'ND 1~b~laNt SERVICES, IT CERTIFIES
<br />THE BELOW TO BETA TRUE COPY OF THE ORIGINAL REEORD ON FILE WITH THE NEBRASICA~PEP,4/:ITfPrIE(~T OF, HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITARY FOR:,V~TAZ~.R`E~(~' _ S; . , '~' , `;
<br />~ •.
<br />DATE OF ISSUANCE - -~ ~~ • • • ... , Y , ,
<br />e ~ 2 010 o s g 7~ .5TA, lVLEY~~~~~~
<br />AUG 1 201 A'$,~ISTA T STF2,Q~t
<br />OE~,~R'TMENT OF HEALTH A'lYR ~ '
<br />LINCOLN, NEBRASKA Hl/Mxtpl•S VICES .~ ~;~ ,`,
<br />STATE OF NEiBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND $LPPpFrQ~:.~' , ~,.; ~.
<br />CERTIFICATE l1F 11FATW ~~ ~~ ,~.
<br />1. PECEgENT'6•NAME (First, Middle, Last, ~ Sufflx) 2. SEX 3. DATE OF DEATH (Mo'Day, Yr.) µ
<br />Donald David Shriner -.., -Mal
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE•L9st Birthday 5b. UNDER 1 YEAR SC. UNDER 1 DAY 8. DATE OF BIRTH (Md., Oay, Yr,)
<br /> (Yrs.) MOS. pAY$ HOURS MINE.
<br />Mercid California 65 March 30, 1944
<br />7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />07-56-1158 HOSPITAL ^Inpalienl 9mE6: ^NursingHvme/LTC ^HaspiceFacility
<br />8b. FACILifV•NAMc (II ndt~~inahtutlpn, give 6treal and number) - '
<br />^ ER/Outpatient l~Dacedent's Hame
<br />4200 South 80th Rd. ^ b~ ^amer(specly)
<br />Bc. CITY qq TgWN pF DEATH (Include Zlp Cvde) 8d. COUNTY OF DEATH ~~~~
<br />Aida 68810 - _ Hall
<br />ga. RESIDENCE•STATE gb. COUNTY ! gc. CI TY O%70WN
<br />Alda
<br />ebraska Hall
<br />___
<br />gd. STREET ANDNOMBER .._. ~ ~~ LL 9e. APT. NO 9t. ZIP CODE 9g. INSIDE CITY LIMITS
<br />200 South 80th Rd. - 68810 ^ YES ~ Ng
<br />~y~~
<br />10a. MA%ITAL STATUS A7 TIME OF DEATH 'JMlarrletl ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Las[, Suffix) It wife, glue maiden name.
<br />^ Married, but separated ^ Widowed ^ Divorced ^ Unknown
<br />Pat Walter
<br />t t. FATHER'S•NAME (First, Middle, teal, 6ufflx) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br />David Shriner _~ ~___Haael Snyder
<br />13. EVER IN U.S. ARMED FORCES? Glve dates of service If yes. 14e. INFO%MANT•NAME 1 ab. RELATIONSHIP TO bECEPENT
<br />(Yes, no. or unk.) Yes 6-62 6-65 Pat Shriner Wife
<br />-...-___
<br />- 15. METHOD OF DISPOSITION 18a.EMGALMER-SIGNATURE i66. LICENSE N0. 16c. bATE (MV., bay, Yr. )
<br />C~Burial ^Donation Not Rmbalmed Aua. 5, 2009
<br />~Cremeticn ^Entombment 18d.CEMETERY, CREMATORY OR OTHER LOCATION CITVlTOWN ~ STATE
<br />^ Removal ^ Other (Speoily)
<br />__ Westlawn_C_ r
<br />e
<br />ma
<br />tory
<br />~ Grand Island NE.
<br />_
<br />_
<br />_
<br />~ •~• ~~'~ "-____
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Tpwn, m
<br />State) --
<br />17b. Zlp Coda
<br />ivin stnn-Sondermann Funeral Home 601 N. Webb Road Grand Tsland, NE. 68803
<br />.,~.
<br />1g. PggT I. Enter the chain of avente--dieeasee, In)urles, or compllcetidne--that directly caused iha death, bo NOT enter terminal events such ae cardiac arrest, APPROXIMATE INTERVAL
<br />reepiratdry arrest, Or ventricular fibrillation without showing the etivldgy. DO NOT ABBREVIATE. Enter only one cause on a Ilna. Add addlllonel Ilnee If necessary. i
<br />IMMEDIATE CAUSE: I onset to death
<br />(a) ~ T
<br />"""' ~
<br />~
<br />IMMEDIATECADSE(Flnal
<br />~-- I
<br />~
<br />`
<br />-•-••..-.-.
<br />-,
<br />' ~--._.- -
<br />dleeesevrwndhlvnreauhln
<br />g DUE TO, OR A$ A CONSEQUENCE OF; _._._._.._.._.._._._._.-._.._._..........__
<br />.
<br />..
<br />I onset tc death
<br />Indeath) i
<br />5equentlally Iletcondltlone, if (b)
<br />any,teadingtothecaueelleted DUETO,ORASACON5EOUENCEOF: I onseuedeath
<br />on Ilse 9.
<br />Enterihe UNDERLYING CAUSE
<br />(dlaaeeedrln(uryfnatlnltieted (c) I
<br />the events resuhing In death) DUE TO, OR ASACONSEOUENCE OF: I dn68t to death
<br /> I
<br />(d) I
<br />18. PART IL OTHER SIGNIFICANT GONpITIONS•Candillons Contributing to the death but ndl resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br />(~
<br />N t~d~Sv+~ CPt~ OR CO%ONE%CONTACTEb?
<br />^ YES
<br />20. IF~FEM'A~E; 21 a.MANNER DEATH
<br />[ 21 b.IF TRANSPORTATION INJURY 21c. WA3 AN AUTOPSY PERFORMED?
<br />^ Homicide
<br />~IVo
<br />o
<br />~w ^ DrivedOperator
<br />I preg
<br />a
<br />nt
<br />ithln past year ^ YES
<br />^ Pregnant at lime of death ^ Accident^ Pending Investlgatlon ^ Passenger
<br />^ Not pregnant, but pregnant within 42 days of death ^ Pedestrian 21 d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />U Suicide ^ Could not ba determined
<br />
<br />^ NrN pregnant, but pregnant 43 days to 1 year belvre death ^ Otner (Specify)
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />^ unknown if pregnant within the peat year A r9/
<br />^ YE$ ^ NO , `~
<br />229. DATE OF INJURY (MO., Day, Vr,) 22b TIME OF INJURY 22C PLACE OF INJURY•At home, farm, street, factory, office building, Construction else, etc. (Sp9olfy)
<br />m
<br />-- _, .......
<br />.... _
<br />22d.INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED ~.._..._.
<br />~r~;:. ^ YES ^ NO
<br />
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT. N0. ~ -~t1, T1'I{C1LgN ~ ~ "' """"" -' ~'-~-`- "- '-^""`^~`""B}P,TL~^"'`~'".'#`m""'=-""`•-"+ZiPCOpL°""^ ~ ~^
<br />' ~ ~ ~
<br />~~ -2~e. DATE OF DE TH (Mo., Day, YG)
<br />~... Z
<br />~,s ~
<br />tx 24a. DATE SIGNEb (Mo., bay, Yr.) 246,TIME OF DEATH
<br />m
<br />$
<br />., .
<br />~ _ .. _Tr._..._... _....__...__....-
<br />23b. bATF„ry^I~N (Mo. ay, Vr.) ---- --
<br />23c TIr(~l ,F,.D~ ~ a ~ ~ 24c. PRONOUNCED DEAD (Mo., Day, Vr,) 24d. TIME PRONOUNCED DEAp
<br />~
<br />4
<br />~ ~ m
<br />~ m
<br />5
<br />~ ~ 23d. To the beat of my knowledge, death occurred at the time, date and place
<br />and due to a cauae(s fated. ~ ature and Title) • $ w ~
<br />~
<br />~ 24e. On the basis of ezaminatlon 9nd/or Investlgatlon, in my opinion death oodurred 01
<br />the time, dale end place end due to the cause(s) stated. (Signature and Tllle)
<br />I°- ~ o
<br /> (Y1~ ~ s
<br />25. DIDT08A000 USE CONTRIBUTETp THE DEATH? 28a.HAS ORGAN OR TISSUE DONATION BEEN CONSIbERED7 26b. WAS CONSENT GRANTED? ~~
<br />YES C-I NO ^ PROBABLY LI UNKNOWN ^ YES NO Not Applicable if 26a i8 NO ^ YES ^ NO
<br />2 A E,~~Gt=AND ADDRE550F CFn%TIFI q (P YSICIAN, CORONC-R'S PHYSICIAN OR OUNTY gRNEY) (Ty eor Prln
<br />~
<br />~
<br />~
<br />~~ ::
<br />.irY•ber Iti,~ N . L
<br />~
<br />28a.REGISTRAR'S SIGNATU
<br />d 266. BATE FILED 8Y REGISTRAR (Mv., bay. Yr,)
<br />G ~ zao9
<br />A
<br /> . E
<br />I, {/
<br />i
<br />HHS-6111/03(55061)
<br />
|