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STATE OF NEBRASKA
<br />WWEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTN„A��ifl' HGlMAN, SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASI� D��PARTM�I�T�OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V.�LAC R�GORDS � �' i`
<br />DATE OF ISSUANCE � Y � � o
<br />,,�'��'� �1,����
<br />02/21/2012 2 0 1 2 0 2 6 7 3 � a��''�_ �°°� E R �;��-
<br />AS'�1S7,41�'.S�',,�T��t�,GISTk�If� ; �
<br />DEPARTM�T •
<br />LIIIICOLN, NEBRASKA IYUNT,�IN. SERVIGE'S ' `
<br />, �, -`
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES •�,�, �� S R ,�; � 12 0�489
<br />GtKlll-IGAItUtUtAIFI s� �_ '•°°. : -
<br />7. DECEDENTS-NAME (Flrat, Mlddie, Last, Suffix) 2. SDC ,` `p_ � f ` -`'3: DATE OF. DEATH (Mo., Day, Yr.)
<br />Emmett Charles Amett Male Pebntary 6; 2012
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUMRY OF BIRTH Sa. AGE • Last Birthday b. UNDER 1 YEAR Sc. UNDER 7 DAY - 6. DATE OF BIRTH (Mo, Day, Yr.)
<br />(Y�•1 MOS. DAYS HOURS MUNS.
<br />Ph(IIIps, Nebraska 72 June 10, 1939
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />505-52-2559 HOSPRAL � InpatleM OTHER � Nmsi� Home/LTC � Hoapice FaeIIHy
<br />8b. FACILITY-NAME pf �rot hreUtutlon, 8ive atr�t artd number) �O
<br />� ❑ ulpatlent ❑ Deeede�rt's Home
<br />� Lakeview-A Golden Living Center ❑�A ❑��IsP�KY)
<br />� 8c. CITY OR TOWN OF DEATH pnclude 21p Code) 8d. COUNTY OF DEATH
<br />o Grand Island 68801 Hall
<br />� �. RESIDENCE�STATE 9b. COUNTY 9c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />LL 9d. 9TREET AND NUMBER 9e. APT. NO. 9I. ZIP CODE 9g. INSIDE CITY UNOTS
<br />2421 N. Grand Island Ave 68803 ��s ❑ No
<br />� 10a. MARPTAL STATUS AT TIME OF DEATH � Marriad ❑ Never fl�rled 1�b. NAME OF SPOUSE (Firaf, Middle, Last, Suftiu) tt wife, g(ve malden martre
<br />� ❑ n�m�ea, b�rt $a��taa ❑ vmao�a ❑ nn�o�ea ❑ u�x�o� Delores �ehman
<br />� 11. FATHER'S-NAME (Firsf, Middle, Last, Suftbc) 12. AAOTHER'S-NAME (Flrsf, Middle, NlaWen S�aname)
<br />m Orville Amett Irene Rediger
<br />�' 13. EVER IN U.S. ARMED FORCESI Cihe dat� of aervice H Yea. 14a. INFORMANT-NAME 1�. RELATfOWSFfIP TO DECEDEPdT
<br />E
<br />$ (ves, No, or unk.) Yes 08/01/1957-07/31/1959 Delores Amett W'ife
<br />,� 1S. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 18e. OATE (Mo., Day, Yr.)
<br />F � Buria� ❑ Donation �urle D. Sheffleld 1397 February 11, 2012
<br />❑ CremaBon Q Errtombment 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Speetfy)
<br />Aurora Cemetery Aurora Nebraska
<br />17a. FUNERAL HOME NAME AND MAILINO ADDRESS (Street, City or Town, State) 17b. Zip Caie
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CA SE F DEATH See InsVuctions and exam les
<br />1& PART L E�rter tde ahatn oi eveMe-4lseasea, InJuAee, a compueado�maha[ mrecGy caused the death. DO NOT eMer terminal eve� sueh ae e¢rdlac artest, ; APPROXINWTE INTERVAL
<br />resplratory artest, or veMriwlar flbriiletlon without showing the edology. DO NOT ABBREVIATE E�rter oNy mre cause on a Me. Add edditlonal W�ea H�. :
<br />IMMEDIATE CAUSE: � onset W deatl�
<br />�rmx�owre �� a) Alzheimers Dementla ; Years
<br />diseaee or eondidon �uWng
<br />� d � ) DUE TO, OR AS A CONSEQUENCE OF: : o�at to death
<br />8equentletly pet eonditlona, N b)
<br />enY. teadin8lo Ure cause Iie[ed
<br />i
<br />on U�re a DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />E�rter the UNDERLYING CAUSE C�
<br />(dlsease or NJury Nat Initiated '
<br />� B �ro"e �^ d�^� DUE TO, OR AS A CONSECUENCE OF: : onset to death
<br />� d) �
<br />18. PART II.OTHER SIGNIFlCANT CONDRIONS-ComilUOns contributl� W the death buc �rot resuitlng In the underlyi� cauae given In PART 1. 18. WAS N�DICAL EXAfY�NER
<br />Coronary Artary Disease OR CORONER CONTACTED7
<br />� ❑ YES � NO
<br />LL 0. IF FEMALE: 21a MANNER OF DEATH 21b. IF TRANSPORTATION WJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />F � NM pregnan! wlthin past year � Natural � Homldde � DrlvedOperator
<br />� Pre9�M at 8me of death � Pesaenger ❑ YES � NO
<br />V ❑ � Accidem � Pending Imesfi8�on
<br />❑ Not PregnaM, but pregna�rt wkhin 42 days ot death � PeAestrlan 21 d. YYERE AUTOPSY FlNDINGS AVAILABLE
<br />� � sutdaa � coma noe ue aemnnuree TO COMPLETE CAUSE OF DEATHT
<br />� Not P�B�, but P�B� 48 daya to 7 year betore deaN � Other (SPecltY)
<br />� � Unimown t( preg�mnt wiMln the past year �� � N �
<br />a 2Za. DATE OF INJURY (Mo„ Day, Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURY•At home, fem4 street, taetory, oftlee buliding, cor�Wetlon efte, eh. (Speetfy)
<br />E
<br />$
<br />.� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />H
<br />❑ YES ❑ NO
<br />22L LOCATION OF INJURY • STREET 8� NUMBER, APT.NO. CfTY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo„ Day, Yr.) 24a. DATE SIGNED (MO., Day, Yr.) 24b. TIME OF DEATH
<br />B February 6, 2012 .� �
<br />��� 23b. OATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ��� Y 24c. PRONOUNCED DEAD (Mo, Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />$ o Februa 14, 2092 08:15 AM g d a�
<br />� 9d. To Ne hest of my Imowladga. death oceurred et the tlme. date a�M ptace $ �� 24e. On the hasls of w�aM�mtlon andfm tnveaUgadm4 In my opinlon dealfi ocartred at
<br />$� and due to fhe causafa) s�ed. (Slgnatuie antl TINe) ��$ the 8me� tlata and Pla� and due to tlre eause(e) �ed.. (8�4��e aeM Tttle)
<br />~� Travis S. Hageman, MD '' g s
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE �NATION BEEN CONSIDERED7 28b. W/6S CONSENT GRANTm?
<br />� YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applicable U 28a Is NO ❑ YES ❑ NO
<br />2. E AND DRE OF FIER {P SI S t T, COR ER PH CO O E1� ype or drR
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGI9TRAR'S SIGNATURE 28b. DATE FlLED 8Y REGISTRAR (Mo„ Day, Yr.)
<br />� February 15, 2012
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