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<br />STATE OF NEBRASKA
<br />�
<br />WHEN THIS COPY CARRIES THE R,4ISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND:HJINFAI�1 ,SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASK�4::C��I��t,�E,�IT Oh NEALTH AND
<br />HUMAN SERVICES; VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V�GAL , J �DS ,, L� ���.
<br />, '` � �Gr, s
<br />DATEC�IFISSUANCE ` jl�f�; ,.,.` ���'�tr ���
<br />� � 0 �.10► 7 2 � 7 �rAN�� �F� COOPE14, ' •. ci r � .
<br />SEP �,0 � 2009 A�L��ANT �'�A;T� I�EG�STR�1}2'� ; � ;
<br />' DFf?�l�l+��'�1F�'O�l�'A�F�1-�'At1%D �_ �;
<br />LINCO�, NEBRASKA MClMA ���/2Vf�E� ; n' ,;,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERYICE'�` '►� � ��` ��
<br />r_GQ-ri��r_er� nG nFnTU r ,: ��'`������ �.�'`
<br />7. DECEDEN7'&NAHIE (Ftret, Mtddte, Last 8uffix) � 2 SEX . � 3. �AT� 7'Fi ( uj;p�,Yt.J� -
<br />. . . ..� ,�. ., . �:� .
<br />Jeannine Jayce Paro Female Sep�ei�b�r�;;�(�D'8.
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Ba. AGE-Last BlRhday 6b. UNDER 1 YFJ1R 8c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Rey: Y�J�' �� �.
<br />(Yrs.) MOS. DAYS HOUR9 MIN9.
<br />Grand Island, Nebraska
<br />7. SOCUIL SECURITY NUMBER
<br />.c
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<br />a
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<br />Bb. FACILITY-NAME (If not Inadtudon, glve atreet and num6er)
<br />Saint Francis Medical Center
<br />Ba CI'IY OR TOYYN OF D�ATH pnclude ZIp Codej
<br />Grand Islartd 68803
<br />9a RESt�ENCE3TATE 9b. COUNTY
<br />Nebraska Hall
<br />9d. STREET AND NUMBER
<br />2011 Grand Island Ave.
<br />10a 67ARITAL STATUS AT TId1E OF OEATH .� Martled ❑ Nsver Ma�
<br />❑ INarrted, but eepereted [� VYldawed ❑ D)vorced ❑ UNmown
<br />11. FATHER'SNMAE (Flrat, Mtddfe, Lest, SuHIY)
<br />80 � �
<br />ea. ru�ce oF neaTr+
<br />HOSPiTAL: Q Urytadan!
<br />� ERlOutpetlent
<br />� [� DOA
<br />March 17, 1929 ,
<br />OTHER: � Nureing Home/LTC
<br />� DecedeM's Home�
<br />8d. COUNTY OF OEATH
<br />Hall
<br />9a CITY OR TOWN
<br />Grand Island
<br />8e. APT. NO. 9L 21P CODE .'
<br />88803
<br />106. NAEAE OF SPOUBE (FGat, 471dd1e, Last, Sufix) B wfie, glve maldan nama.
<br />George Roy Paro
<br />12 MOTHER'S-NAME (Flrst Mlddle, Malden Sumame)
<br />1A EYER !N U.S. ARMED FORCES9 (3fve datea of servfce H Yes. 14a. MFORMANT•NAME
<br />(Yes, ruo, or Unk.� No Geor e Ro ro
<br />18. METHOD OF DISPOSITION 18 MERS16
<br />�� 0�� Cc� c �
<br />❑cr�m,o� ❑�aaw�a
<br />� �� C ETERY,CREMATORYOROTfiERLOCA77QN
<br />Westlawn Memortal Rark Cemetery
<br />77a �FUNERAL HOME NAME AN� MAILINQ AD�RE89 (8basi, Clry or 7oxm, 9fefe)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />raeWrato,Y enaet. orvenUleuler HGrAletlon wlthoW ahawtng tlre a8otogy.
<br />IMM '1� CAU6E:
<br />IMEpEDIATE CAUSB (Flna1 �
<br />dlseaea a) p
<br />ln tleath)
<br />DUE TOsb� A9
<br />Seqnentlally Ilat wndldons, !f b) � p a ���
<br />anri leauing to the ceuse Ustetl /�`} %�
<br />°� ��� e ' DUE'f0, OR AS A CONSEQUENCE OF.
<br />Enter tha UNDERLYING CAUSE �) .
<br />(dtsease ortrtJury that Wtlaled �
<br />the eveMs resultlng In death) pUE TO, OR AS A CONSEQUENCE OF:
<br />LA9T
<br />18b. LICENSE NO.
<br />/0397
<br />CITY/TOWN
<br />Grand Island
<br />� Hosplea FaclRty
<br />eB. uus�oe crrr un�rrs
<br />� Yea � No
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />tec. OATE (Mo., Day, Yr.)
<br />STATE
<br />Nebraska
<br />88801
<br />i0 NOT mnaz terminal evaMe euch es caMlae artea;
<br />ly orre eause en a Me.Adtl adAftlonal Wres rc neceaea�Y.
<br />� � G�C.XG{sr't.Z-
<br />2�-i ��c�-��-
<br />d)
<br />18. PAR � THER SIGMFICAI+IT CONDITIONS-Co�lltlons conMbuting to the death but not rasultl� tn the unde�Iying cause gtven tn PART L
<br />� �1��.�c.-��- 1�. �.�..e�°
<br />W ( Z��-��F F : 2 MANNER OF DEATH 21b. IF TRANSPORTATION INJUF
<br />� ��Ppt pregnant wtthln paet year �Natural ❑ Homlctde ❑ DrlvedOperato►
<br />� 1LI r��ent at dme of death ❑ Acddent �❑ PetMfn9 �estl8�on ❑ Passertger .
<br />. ❑Not pregnanf, but pragnarrc wfthtn 42 days of death ❑ 3utctQa ❑ Cwi1d no! be tleter�il�red ❑ Padas4lan
<br />.0 ❑NM pregnant, but pregnant 43 days to 1 year bePore death � ❑ Other (8p�(ty)
<br />� QUntmown If prognent wNhln tfre paet yeer �� � .
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<br />a
<br />� .._�.........�....�..�.
<br />i
<br />� o�reet to deeth )
<br />' � r�a�..cY Ll.�.
<br />�
<br />� aireet to death
<br />�
<br />�' ��
<br />onset tp dea
<br />�
<br />� onset W deeth
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<br />18. WAS fdEDICAI EXAMINER �
<br />OR CORONER CONTACTED4
<br />❑ t�s No
<br />z�c. was nta auroPSr P�oRmeoa
<br />❑ YES �NO
<br />21d. WERE AUTO FlNDIN6S AVAILABLE
<br />TO COAAPLETH CAUSE OF OEATHI
<br />❑ YES �QO
<br />��
<br />0 22a. DATE OF WJURY (Mo, Dey, Yr.) Ttb. TINIE OF INJURY 22c. PLACE OF tNJURY-At home, fam�, atraet, facMry, offlca bulldtng, construcUon aka, etc. (Spealfy)
<br />t� m
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<br />m 22d INJURY AT ORK4 22e. OESCRIBE HOW INJURY OCCURRED ' `
<br />FQ- .. . . . � -- - � -
<br />❑ YES O
<br />22L LOCATION OF INJURY - STREET & NUMBER, APT. NO. C�TYROWN
<br />23a. DATE OF DPATH (Mq„ Day, Yr.) �
<br />a W September 2, 2009
<br />�� Zib. �ATE SIGNED (Mo., Dey, Yr.) 23a TIME OF DEATH
<br />E v Z� r 2� 20(39 8: 35 a m
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<br />To the ot my knowledgp, death �curted et the 6me, date and placa
<br />� � . mW th�cauae(s�,F�Stgneture 8rM Title)
<br />A A
<br />26. DID7p BACC USE CONTRIBUTE TO THE EATH? 28a HAS OROAN OR
<br />0 YEB NO ❑ PROBABLY UNKNOWN ❑ YE9
<br />27. W4ME, tE ANQ ADDRE33 OF C�BR (P CIANNY P13 , HY81CU1N ASSISTANT. C
<br />John A.Wagoner M,D., 800 Alpha Street G�
<br />28a. REGISTRAR'S 8I6NATURE .
<br />P
<br />�
<br />BTATE � ZIP COOE
<br />� 24a �ATE 6tGNED (Mo., Day, Yr.) . 24C. TfME OF DEATH
<br />. c z m
<br />p� y O x4c, PRONOUNCED DEAD �Mo., Day, Yr.) 24d. TIpAE PRONOUNCED DF,AD
<br />bx k�
<br />aa Q Z m
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<br />���� 24e. On Ure bflals ot axeminatlon amllm ImesUgatlon, ln my oplMon death occ�ured
<br />o .� O ae tha nme, dam ana p�ace and ana w me cause(s) smced. �Slgnaeure ana Ttue)
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<br />i0NAT10N BEEN CONSIDEREb? 28b. WAS CONSEN'f ORIINTEO?
<br />NO � Not Appllcabl6 H 28e la NO ❑ YES �
<br />'S PHY9ICIAN OR COUNTY ATTORNEI� (Typa or PrIM)
<br />Island NE 68803
<br />28b. DATE FlLED BY REGISTRAR (Mo., DaY. YrJ
<br />ti SE� � . � 2oos
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