|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE N�BR.4$KA DEPARTMENT OF H,EALTH+ad'ML"��ICll�l',� �RVIC�'S,. IT CERTIFIES
<br />THE 19ELpW TO BE A TRUE CPPY pF THE QRIGINAL RECpRD ON FILE WITH THE NEBRA,,;'�IC,4 h1EALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFF[CE, WHICH IS THE LEGAL DEP�SITORY FOR t/I.PAt'I�ZEC S `'� ,�
<br />, , • ,� p� � 7 �
<br />DATE OF ISSUANCE /�w�� " ��1
<br />2oioos53� 5����E� G P � ..,,,.; �
<br />09/20/2010 A�SI9TA�S�T�t�G1$�R,�.1�'t: r* ':
<br />CiE��RTIN C��� AL�F`I �}NC? ,-'
<br />LINCOLN, NEBRASKA HUM�91,V•SF,�t��E�` . � `'
<br />S7A7E QF NE9i2ASKA - D�PAR7M�NT bF HEALTH AND HUMAN SERV�ICE «� }�=� f.��, `'��' �•� ",.. � O OZ622
<br />r��rw���ir_eT� n� n�eT� , „,. •-...... .,�.,� �..
<br />1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX ti,� ' 3': DA7� pF REATH (MO., Day, Yr.)
<br />Lyle Clalr Orcutt Male "`�`'� �S�p��mber 14, 2010
<br />4. CITY AND $TATE OR TERRITORY, OR FOREIGN COUNTRY OF 91RTFI 5a, AGH � Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs.) Mpg. DAYS HOURS MINS.
<br />Hall Counry, Nebraska 76 September 7, 1934
<br />7. SQCIAL $ECURITY NUMBER 8a. Pl.ACE OF DEATFI
<br />507-48-5887 �[] InpatlarH QT� ❑ Nur�ing Home/L7C � Hosplce Facil�ty
<br />8b. FACILITY•NAM� (If not Instltutlon, qlve atraet and numder) ��Wputpatlerk � DecederH's Nome
<br />K
<br />� 128 Mqnument Rpad � DDA Q pther ($pecliy)
<br />, ..__ _ ... ..r
<br />�� 8c. CITY OR 70WN QF DEA7H (Includa Zip Coda) 8d. COUNTY OF DEATH
<br />p Doniphan fi8832 Hall
<br />� J 9a. RESIDENGESTATE 9b. COUNTY 9a CI7Y OR TOWN
<br />Nebraska Hall Doniphan
<br />LL 9d. $TREET AND NUM6ER e. APT. NO. 9f. ZIP CODE 9g. INSIDE CITY LIMIT$
<br />�, 128 Monument Road 68832 ❑ res � No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH � AAarrlad ❑ Never Marrled tOb. NAME OF SPOUSE (Flrst, Middle, Laat, Suffix) H wifa, plve maiden name
<br />!� ❑ Marrlad, but separated ❑ Wldowed ❑ qlvorced ❑ Unknpwn Patricia fAflfl 7hein
<br />m
<br />� 11. FATHER'3•NAME (Flrst, Mlddle, Last, Suffix) 12. MOTHER'S-NAME (Firat, Middle, Nlaidan Surname)
<br />� �red Orcutt Joanna Bischel
<br />E 1s. EVER IN U.S. ARMED FORC�S? Giva datas oi sarvica if Yas. 14a. INFORMANT-NAME 74b. RELATIpNSHIp TO DECEDENT
<br />y �vas, No, or unk.► No Patricia Orcutt Wife
<br />a 75. METHOD 4F DISPOSITION 18a. �MBALMERSIGNATUR� 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />° � eurlal ❑ Ponatlon
<br />� Daniel D Naranjo 1071 September 18, 2Q1Q
<br />❑ Crematlon ❑ Entombmant 78d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / 70WN STATE
<br />[] Removal ❑ Othar (SpaclTy)
<br />Cedarview Cemetery Doniphan Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty pr Tpwn, Spte) 17p. Zlp Coda
<br />All Faiths Funerai Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />AU E ee instructions and exam les
<br />iB. PpRT I. EntBr the cha�n oj�(@n��diWiw�, IrlJudea, or compllCitlonl�thN tllroCtly cauwd thr daath. oo Np7 snter esrminal ewms auch aa CiMlae arreat, ; APPROXIMATE INTERVAL
<br />ro8p11'dtary a/IBM, or vanMcular 116Alletlon witnollt ihOWinp the etiolopy. �0 NOT A88REVIATE. EMar only ona cauM on � 11n9. Add addltlonal IInYa It nsaS6iry.
<br />IMMEDIATH CAUSE: ; onaet to daath
<br />IMMEDU.TE CAUSE (FII1al e) Carcinoma Of The Bladder ; 2 Years
<br />tllwaK or conditlon roouttinq
<br />In daam� pUE TO, OR AS A CONS�QUENCE O�: ; onsat to death
<br />Srqurntlally Ilst condlllons, If b)
<br />- - NIry;lMtlhry w itlr'c11rw�NMad� - . ,. _ . . . _ .. .. . w . - ..•-. .. .... , .. . - � . , . . . . . .- _ .
<br />on Ilne a.
<br />DUE TO, OR A5 A CONSflQUENCE OF: ; onsat to death
<br />Entar thr UNDERLYIN6 CAUSE C )
<br />�dlasaaa prinJurythiliniqdted
<br />ehe avanes reaultiny In death) DUE TO, OR AS A CONSEQIIENCE OF: 7 onsat to death
<br />�asr d)
<br />18. PART II.OTHER SIGNIFICAN7 CONDITIONS•Condltlons contrlbuting to tha death but not resulting in the undarlylnp causa piven In PART I. 19. WAS M�DICAL EXAMINER
<br />pR G�RpN@R CONTACTED9
<br />� Q YE$ � NO
<br />� 0. IF FEMALE: 21a. MANNER OF qEATN 21b. IF TRANSPORTATION INJURY 27c. WAS AN AUTOPSY PERFpRMEq7
<br />LL
<br />� � Npt preanam wknln part year � Natural � Homiclda �] Ddy9rlOpBrAtor
<br />� � ProqnaM at tlme of death � p�cldent � Pendiny Invenlpallon ❑ Paassnper � YES � NO
<br />� � Not prepnam, but prepnant wkn�n 4z naya of daath � swcma � COUTA not be AataYminid ❑ Padenrlan 21d. WER� pUTOPSY FINDINGS AVAILABLE
<br />� Not prepnant, 6U� propnant A8 ddy6l0 1 yldl' bllOro dBdih � Other �Speciry� TQ GOMPLETE CAUSE OF DEATH?
<br />� UnknOwn If propnaM wRhln fhe paat yaar
<br />❑ res ❑ No
<br />°' 22a. PATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLAGE O� INJURY•At home, farm, street, factory, ottice bullding, constructlon sita, atc. (SpecHy)
<br />E
<br />$
<br />� 22d. INJURY AT WORK7 22e. DESCRIeE HOW INJURY OCCURRED
<br />O
<br />� ❑ YES ❑ NO
<br />22f. LOCATION OF INJURY • 3TREET 8. NUMBER, APT.NO. CITYITOWN $TATE � ZIP CODE
<br />23a. DATE QF DE4TH (Mp., Day, Yr.) 24a. �ATE SIGNED (Mp., Day, Yr.) 24b. 71ME OF pEATM
<br />� s September 14, 2010 S�
<br />�� � 2sb. DATE $IGNEO (MO., Day, Yr.) �3c. TIME OF DEATH � k � 240. PRpNpUNGEb DEA� (MO., �ay, Yr.) 24d. TIME PRONOUNCED DHAU
<br />-� 5e tember 16 2010 09:10 PM �� �
<br />$ � 3d. TD tba peat of my knowlOApa, drath oCCUfretl at thr tlmr, data and plau �� O pqg, On flli Gafia of rxfminatlon andlar Inveallqa(lon, ln my OpinlDn dsath pccWled it
<br />$� and dua t0 tde Cau6ele) mtatad. (5lpnature and Titla) .$�� ths tlms, dats and placa and dua ro the caue9(e) 8fatee. (Siqnature and Titla)
<br />~ � James W. Miller, Mp ~ $ ;
<br />25. DID TqBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN qR TI$SUE DONATION BEEN CONSIDERED? 266. WAS CONSENT GRAN7ED7
<br />❑ YE8 � NO ❑ PROBABLY �] UNKNpWN � YFS � NO Not Applicabla If 28a Is NO ❑ YE5 ❑ NO
<br />Z• A . � ype or nt
<br />James W. Miller, MD, 1021 W 14th St., P.O. Box 968, Hastings, Nebraska, fi8902
<br />288. REGISTRAR'S SIGNATIIRE 286. DATE FILE� BY REGISTRqR (MO., Day, YY.)
<br />September 17, 2010
<br />
|