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STATE OF NEBRASKA _ �', (j i � 0 � � �
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTM�111� QF tt�I�ti7"Ft �1? �UI!'�i�W 9El�?VtCES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITfd' �'�IE' NE�i�,1 ��9 d�'PAf�TA9�N7T i3F' �7E,4L•TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DERDSITQk�'Q�2_�/�F1 �t�CC3RD� t`
<br />' -:•�-�+r�'' �, ��"
<br />DATE OF ISSUANCE . �.� '�, � � ��
<br />12/02/2011 � � + S'�AN��S. GG10QFR ,,, �i -
<br />2 a 1 2 0 0�(� .,� r ASSI�•49V�1' S��`EIT�GIST!?AR -
<br />- _ �D�',PARTMERIT�7�'_d-1�'ALTH,,�6�ID
<br />LINCOLN, NEBRASKA �, ��Fl1�I.�JiJ��k�t"C�� : ��-
<br />STATE OF NEBRASKA - DEPARTMEN7 OF HEALTH AND HUMA�1 SE�i/(6�r �� ��� � ,-'� � � � 03955
<br />CERTIFICATE OF DEATH - : � ^: d„, . •
<br />1. DECEDENT9-NAME (First, Middle, Last, Suft�c) Z SEX @ e , S. DATE OF DEATH (Mo., Day, Yr.)
<br />Scott Lee Crawford Male � November 28, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREION COUNTRY OF BIRTH Sa. AGE • Last BlRhday b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y�•) MOS. DAYS HOURS MINS.
<br />Le�cington, Nebraska 48 July 17, 1963
<br />7. SOCIAL SECURI7'Y NUM9ER 8a. PLACE OF DEATH
<br />506-84-8156 SNO PRAL � InpaUe� OJHER ❑ Nursl� HomefLTC � Hospice Factltty
<br />8b. FACILITY•NAME pf not InstltuUon, give street ami number) � ER/Outpatlerit ❑ DecederR's Home
<br />�
<br />� BryanLGH Medical Center East ❑ DOA ❑ o�ner(speoiry)
<br />W Sc. CITY OR TOWN OF DEATH pnclude Zip Code) 8d. COUN7'Y OF DEATH
<br />�
<br />o Lincoln 68506 Lancaster
<br />� 9a. RESIDENCESTATE 8b. COUNTY 8c. CITY OR TOWN
<br />Z Nebraska Hall Doniphan
<br />�7 8d. STREET AND NUMBER 8e. APT. NO. 9f. ZIP CODE 8g. INSIDE CITY LIMIT3
<br />� 3890 West Rosedale Road 68832 ❑'r�s � No
<br />'� 10a. NWRITAL STATUS AT TIME OF DEATH � Nlar►ied ❑ Never Martied 10b. NAME OF SPOUSE (Flret, Npddle, Last, Sufthc) H wHe, g(ve maiden rmme
<br />� ❑ Marrled, but separated ❑ Widowed ❑ D(vo►ced ❑ Unknown Peggy BfOW�1
<br />� 11. FATHER'3-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (Flrst, Mlddle, Maiden Sumame)
<br />� Gaylord Lee Crawford Carolyn Jean 'Schutte
<br />°' 13. EVER IN U.S. ARMED FORCEST Gtve dates of aervlee H Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEOENT
<br />E
<br />$ �Yas, No, or unk.) No Pegg CrawFord Wife
<br />,� 1S. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F � Burial ❑ Domatlon
<br />L. Todd Biester 1152 December 3, 2011
<br />❑ Crert�don � EMOmbmeM �8d. CEMETERY, CRENWTORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (SpecHy)
<br />Concordia Cemetery Junlata Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUN(i ADDRESS (Straet, City ot Town, State) 17b. Zlp Code
<br />Llvingston-BuUer-Volland Funeral Home, 1225 N. Elm, Hastlngs, Nebraska 68901
<br />CA E OF DEAT See instructions and exam les
<br />1& PART I. E�rter the chaln ot eveme• �dlseasee ln)utiea, or complicado�-ttmt tlireetiy wuwd tde death. DO NO7 e�Uettermtrml ereMe such ea cardiac errest, � APPROIOMATE INTERYAL
<br />reepiraWry arreat, or veMrlcular flbrillatton wtthout ehowing Ure eGOtogy. 00 NOT ABBREVIATE. E�rter only orre cauw on a 16re. Add addidonal W�es IT necessary.
<br />IMMEDIATE CAUSE: ; o�et W death
<br />IMMEDIATE CAUSE (Flnal a) End Stage Liver Disease ' Y��
<br />disease br cond�ion reaulting �
<br />�" °�'� OUE TO, OR AS A CONSEQUENCE OF: � a� � d��
<br />s�,��rn�e�o�an,o�arc b)AlcoholicCiRhosis � Years
<br />a�ry, leatling to the puse Iisted
<br />on Me a DUE TO, OR AS A COkSEQ�JENCE OF: : o�et to death
<br />Enterthe UNDERLYING CAUSE C�
<br />(dl9ease orinJurythatlnitlatetl
<br />ue 8"e"re'ee'nu"e �" °e�u'� DUE TO, OR AS A CONSEQUENCE OF: 7 onset to death
<br />�T d� �
<br />18. PART II.OTHER SIGNIFlCANT CONDRIONS-CorMltio� conMbuting to the death but not resulUng in the umlerlying quea given in PART 1. 18. WA3 MEDICAL EXAMINER
<br />Hepatorenal Syndrome, GastrointesUnal Bleed, Severa Malnutrition, Spontaneous Bacterial Peritonitls OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />LL O. IF FEMALE: 21a. MANNER OF DEATH 27b. IF TRANSPORTATION INJUR 21e. WA9 AN AUTOPSY PERFORMEDT
<br />� � Not WeBna�rt within past Year � nt�a� � r+o,m�ae ❑ umrenoae�m. � vES � No
<br />V ❑ Pre9��n at tlme of death � Rassenger
<br />� AccldeM � Pending Imesfleatlon
<br />� Not pregnarrt, but pregna�R withln 4Y days oi tleath � Pedaetrian 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />�+ SWdde CoWd not be determined
<br />'� � Not pr�nartt, but pree� ��Ye to 7 year berore deam � � � p� �gp�y� TO COMPLETE CAUSE OF DEATHT
<br />� � Unlmmm It pregna�rt withia the Peat Year . ❑ YES ❑ NO
<br />Q ' ?2a. DATE OF INJURY (Mo., Oay, Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURY-At home, (arm, atreet, factory, oftlee building, w�retruction slte, ete. (Speefiy)
<br />E
<br />$
<br />� 22d. INJURY AT WORK? Yle. DESCRIBE HOW INJURY OCCURRED
<br />I�-
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) � 24a. DATE SIGNBD (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />B� November 28, 2011 a�
<br />� �} 23b. DATE SIONED (Mo., Day, Yr.) 2Sc. TIME OF DEATH ���} 24c. PRONOUNCED DEAD (Mo„ Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />Z November 30, 2011 08:15 AM � a o
<br />$� � Sd. To the best of my knowted9e� death occurted at flre dme. date end ptace °�� 24e. On tlm hasis ot mm�Nnatlon mMlar ImestlB�. M mY opinlon death oaurred at
<br />�� w�a m,e ro tne eau�gl �ma. tsi9nawre ana rwel � o� the dme, Aafe and place end due to Hre muselal stated. ISIgnaW re and Tit191
<br />~ Michael A. Furasek, MD `' g s
<br />25. DID T08ACC0 USE CONTWBUTE TO THE DEATH7 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED7 28b. WAS CONSENT GRANTEDI
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN � YES ❑ NO Not Applicable ff 28a Is NO � YES ❑ NO
<br />27. TITLE OF C RTIFIER (P SICIAN 1 , C R ER S PH OU A EY) (1'ype or PMnt)
<br />Michael A. Furasek, MD, 2300 S 16th, Lincoln, Nebraska, 68502
<br />28a. REGISTRAR'S SIGNATURE ���� `� 26b. DATE FlLED BY REGISTRAR (Mo.� DaY. Yr.)
<br />December 1, 2011
<br />p�i OTj�i
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