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�TATE OF NEBRASKA
<br />��� �
<br />WHEN THIS COPY CARRlES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HFAL,TH��1'�D, � IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE'CORD ON FILE WITH THE �VEBR�IS,�t'A ���1�'R�t'7��I�IVT"OF'f�`IEALTH AND
<br />NUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY �'�iR VITi4�L a�E�'(� �. >'
<br />� �; ' ,. �'
<br />DATE OF ISSUANCE +� ; , ", ' • +`
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<br />� � �v �� S�`�II�E.Y.S �QC3��ER �. �+, ,;
<br />04/20/2011
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<br />'�Q�,�r��hiE�vr o� y�a��y ,a�'o . ; �
<br />LINCOLN, NEBRASKA h(UV�jA��SE���CES r ;; �, �'. �`
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIG'ES , � a � ��.�q' ��" � 4 ' , ��� *� 7
<br />4�.`� { 11 01268
<br />CERTIF(CATE OF DEATH �� �v N�•,,��� � �> -., ":, �� N:�
<br />DECEDENT'S•NAME (Flrst, Mtddle, Last, SufBx) 2. SEX -' �3: OF qEATH (Mo, Day, Yr.)
<br />Wallace Albert Johnson Male April 2011
<br />CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last BlRhday b. UNDER 1 YEAR Sc. UNDER 7 DAY 8. DATE qF BIRTH (Mo., Day, Yr.)
<br />(�'B•) MO3. DAYS HOURS MINS.
<br />Grand Island, Nebraska 82 January 7, 1929
<br />SOC1A1 SECURITY NUMBER 8a. PLACE OF DEATH
<br />50F)-20-4697 OH SPITAL � InpaUeM OTHER � Nuwing HomeILTC � Hosplce Facltity
<br />a. - V cN.....yaunua V vwwnn[» nvma
<br />� Tiffany Square Care Center ❑ ooA ❑ Other (Specffy)
<br />� Sc. CIIY OR TOWN OF DEATH Qnclude Zip Code) 8d. COUNTY OF DEATH
<br />c Grand Istand 68803 HaA
<br />� 8a. RESIDENCESTATE 8b. COUNTY 8c. CITY OR TOWN
<br />z Nebraska Hall Grand Island
<br />7� 9d. STREET AND NUMBER 9e. APT. NO. 8f. ZfP CODE 9g. INSIQE CITY LIMITS
<br />63Q Ravenwood Dr. 68801 � ves ❑ No
<br />� 70a. MARI7AL STATUS AT TIME OF DEATH � Marrlad ❑ Never Married 10b. NAME OF 3POUSE (First, Mlddie, Last, Sufthc) H wHe, gWe maiden name
<br />� ❑ Marrled, but separated ❑ Wldowed ❑ Divorced ❑ Unktrown Kathryn Harder
<br />� 11. FATHER'S•NAME (FlBt, ANddle, Last, Suffbc) 12. MOTHER'S•NAME (Flret, Middle, Mlalden Surname)
<br />m Albert Johnson Ruth Whitt
<br />£ 13. EVER IN US. ARMED FORCES? Give dates of serviCe HY�. 14a. INFORMANT•NAME 94b. REtAT10NSHIP TO D$CEDENT
<br />$ �res, No, or unk.� Yes 03/17/1952-02/27/1954 Kathryn Johnson Wife
<br />,� 15. METHOD OF DISPOSRION 18a. EMBALMERSIGNATURE 18b. UCENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />� ❑ aunai ❑ oor�Uon Not Embalmed April 18, 2011
<br />� CrertraUon Q E�ombment 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removai ❑ o�na� �saecKy) �ntral Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MPJLING ADDRESS (Streat, Cily or Town, State) 1Tb. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand lsland, Nebraska 68801
<br />�
<br />I& PAR1' 4 EMer the�hain of evarne..dlseasea, InJuries, or eomplicatlona•that dlrecUy cau�d the death. b0 NOT eMer terminel eveirte such ae cardfac errest,
<br />resplratory artest, or veirtrlcular flbrUlatlon without showtng the etiology. DO NOT ABBREVIATE. F�nter oniy mre muse on a prre. Add atlditlanal Ii�res Kneceasery.
<br />IMMEDIATE CAUSE:
<br />imnaeow� cnuse �nei a) Acute Renal Failura
<br />dtsease or conditlon resutting
<br />�° �'� DUE TO, OR AS A CONSEQUENCE OF:
<br />s��emmu uee �o�amo�, rc b) Pneumonia
<br />aoy. leaaing so the cause tlsted
<br />on 11rta a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />EnterUre UNDERtYiNO CAU3E ��
<br />(Waease or InJury that IniGated �
<br />Ure eve"m reev�a"¢ �" death� OUE TO, OR AS A CONSEQUENCE OF:
<br />� d)
<br />3. PART 0. OTNER SIGNIFlCANT CONDITIONS�ortditlo� cortl
<br />Myelodysplastic Syndrome, Hypartension,atrial Fibrillation
<br />�
<br />LL 0. IF FEMALE:
<br />� � No! We9nar» wtthin A� Yeer
<br />w � aregnenc at ume ot aeath
<br />V
<br />� � Not pregna�, 6ut pregnaM wfthln 42 days of death
<br />� � Na wee�a�e. bue are¢�enr aa dey8 �o � year neror� aeaa,
<br />m ❑ Unknown H Pre6nant wkhln the P� Y�
<br />� 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF R
<br />$
<br />.� Ytd. INJURY AT WORK? 22e. DESCRfBE HOW INJURY �
<br />0
<br />f" ❑ YES ❑ NO
<br />22G LOCAT(ON OF INJURY - STREET & NUMBER, APT.NO.
<br />APPROXIMATE
<br />o�reet to death
<br />Days
<br />o�ei to death
<br />Days
<br />onsetto death
<br />onsatto death
<br />to the tleath but rrot resulting in the wnleriyl� cause glven In PART I. 19. WAS MEDICAL EXAANNER
<br />OR CORONER CONTACTED?
<br />❑ YES � NO
<br />:1a. MANNER OF DEATH 21b. IF TRANSPORTAT(QN INJURY 27e. WAS AN AUTOPSY PERFORMED7
<br />p r�w�, p Ho�uaae ❑ o�ao
<br />❑ Pe ���� ❑ YES � NO
<br />� AedtleM � Pending InveatlgaGon
<br />� Sulclde � Could not be determined � P�estrte" 21d. WERE AUTOPSY FlNDlNGS AVAILA
<br />[] Othar (SpeWfy) TO COMPLETE CAUSE OF DEATH4
<br />❑ YES ❑ NO
<br />JURY 22c. PLACE OF INJURY•At home, farm, atreet, factory, oftice bulldinp, co�tructlon sRe, etc. (Speciry)
<br />CITNROWN
<br />STATE
<br />ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) � 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />Apri(16, 2011 � �
<br />� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ��� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� Z A ril 19, 2011 07:00 AM �<�
<br />� � . To the best of my Imowledge. aeeu, a�r�ea as �ns nme, date entl place 8� °
<br />aml due W the cauae(s) etated. (SlgnaWre and Tttle) � Z 2qe. On the baels M examinatlon and/or InveaUgation, ln my opinion daaM oceurted at
<br />9 0 �$ the tlma, tlate and place and due to the ceuse(e) afated. (S19naWre and Title)
<br />< Jay C. Anderson, MD '' $ ; --
<br />,.J YES �„J NO [„J PROBABLY � UNKNOWN ❑ YES
<br />IAME, TiTLE D CE Fl R 9 lA , HY$fGl�Si
<br />lay C. Anderson, MD, 729 North Custer Avenue, Grand
<br />REGISTRAR'S SIGNATURE �_''� r ' � '�
<br />� NO Not Applicable H28a Is NO � YES [] NO
<br />, C�ONER' C OR O NT�A� RNEY) (Type or Prirrt)
<br />Nebraska, 68803
<br />�� 28b. DA7E FlLED BY REGfSTRAR (Mo„ Oay, Yr.)
<br />_ _ April 19, 2011
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