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` STATE OF NEBRASKA
<br />i .
<br />WHEN THIS COPY CARRIES THE RAI5ED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH �1ft� fi1�A7�Flt� � VICES, IT GERTIFIES
<br />THE BE�OW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA5/lx1�D�R,J�FM,�IUT �F HEALTH AND
<br />HUMAN SERVICES, V1TAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR t�fT� ''f2ECORDS :��
<br />� J � � j : , 7
<br />DATE OF ISSUANCE : ,� .• �' �
<br />L�7�i �-r�.
<br />07/14/2011 2 012 0 3 5 7'7 �.� AN;�: ����F�I��R" ;;
<br />�.
<br />DE'P/{RTfi1El�11`CSF`�I�EAT.Tf�;41YD ,=
<br />LINCOLN, NEBRASKA H�IMAV�SER,VIG�S . �s, �
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVI���' ��' ��� �" '�� �. •��, x�
<br />f+C�TICl/+ATC AG 11C ATLI �- . r��t` r '' � ..��. ; .`= �''-' . '-, � _` 11 02333
<br />..�... .. ....-.. ,
<br />1. DECEDENTS•NAME (First, Middle, last, SuHlx) 2. SEX :. s, . DATE OF DEATH (Mo., Day, Yr.)
<br />Stephen Arthur Glade Male ``July g; 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yre•) MOS. DAYS HOURS MINS.
<br />Grand Island, Nebraska 64 October 20, 1946
<br />7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />508 HOSPITAL � InpaUent OTHER � Nursing Home/LTC � Hospice Fac►Ilty
<br />Sb. FACILITY-NAME (H not Instttution, give street and number) � ER/Outpadent ❑ DecedenYs Home
<br />�
<br />� St. Francis Memorial Health Center LTC ❑ oon ❑ Other (SpecHy)
<br />�
<br />� 8c. CITY OR TOWN OF DEATH (Ir�cluda Zlp Code) 8d. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 9a. RESIDENCESTATE 8b. COUN7Y 8c. CITY OR TOWN
<br />z Nebraska Hall Grand Island
<br />� 8d. STREET AND NUMBER 9e. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY LIMITS
<br />�` 2022 Bafiara Avenue 68803 ��s ❑ No
<br />>�
<br />� 10a. Nu4RITAL STATUS AT TIME OF DEATH � Married ❑ Nevar Married 10b. NAME OF SPOUSE (Flrat, Mlddle, Last, Suflix) N wBe, 8�e malden rome
<br />� ❑ Married, but separated ❑ Wldowed ❑ Dlvorced ❑ Unknown Debra SU8 Webben
<br />m
<br />� 11. FATHER'3-NAME (First, Mlddle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Sumame)
<br />� Fred Manroe Glade Amanda Dagmar Pedersen
<br />E 13. EVER IN U.S. ARMED FORCES7 Give dates ot sarvice If Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ nes, No, or unk.) No Debra Sue Glade Wifa
<br />,� 15. METHOD OF DISPOSITION 18a. EMBALfMERSIGNATURE 18b. LICENSE NO. 16e. DATE (Mo„ Day, Yr.)
<br />F ? ❑ Burial ❑ DonaUOn Not Embalmed July 12, 2011
<br />� Crematlon ❑ Errtombmerrt �Bd. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (SpecHy) Central Nebraska Crematlon Services Gibbon Nebraska
<br />77a. FUNERAL HOME NAME AND MAILINO ADDRESS (Street, Ctty or Town, State) 17b. Zlp Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See instructions and exam les
<br />t8. PART L EMar tha chain oi eveMa� �tl�aeasea, injuries, or compllcetiona-tha! dlredly quaed the tleath. DO NOi eNar terminal everrts euCh 88 Cardiac erte8k � APPROXIMATE INTERVAL
<br />reapiratory arreat, or venMCUlar flbrillaGon without ahowing the edology. DO NOT ABBREHIATE EMer only oIre cauae on e Iine. Add addMlonal Iines Ii neeeseary.
<br />IMMEDIATE CAUSE: ; onset to death
<br />INIMEDIATE CAUSE (Final a) Pneumonfa ; 7 Days
<br />diseaw or condWon reautting
<br />1° d �� DUE TO, OR AS A CONSEQUENCE OF: : o�et to death
<br />s�q�e„neny i�e �mm�o�, n b) Metastatic Non Small Cell Lung Cancer : 6 Months
<br />anY. leadine M the cauae Ils[ed
<br />on nne a. DUE TO, OR AS A CONSEQUENCE OF: � onsat to death
<br />Eirter the UNOERLYIN6 CAUSE C �
<br />(dl�a� ar InJury that Infdatetl
<br />the evente reeuldng In tleath) DUE TO, OR AS A CONSEQUENCE OF: = o�et to death
<br />LAST d �
<br />18. PART 11. OTHER SIGMFlCANT CONDITIONS-Condltlo� cantributing to the death but not resulting In the underlytng cause given In PART I. 19. WAS MEDICAL EXAIVONER
<br />ChfoniC ObstnlCtive Pulmonery Disease OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21e. WAS AN AUTOPSY PERFORMED?
<br />� � Not pre8nvrt wfthln P� Y� � r� � Ho�u�iae �] o.�noa�� � yES � No
<br />W Pregnant at time oi death � Pas�nper
<br />V 0 � Accldent � Pendinp ImeaGgaUon
<br />A � Not preB�M. bu! prepnant wkhin 42 daye oT death � vedestr�an 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />' � Not pregna�rt, but pragnaM 43 tlaye to 1 year betore deaUt ❑ Suidde � Could not be determined ❑ � r (g��) TO COMPLETE CAUSE OF DEATH7
<br />� � UnknownRDreBnarrtwith�nthePaetYear ❑ YES ❑ NO
<br />°' 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY Z2c. PLqCE OF INJURY-At home, farm, atreet, factory, oftice buliding, consWCtion alte, etc. (Specify)
<br />E
<br />s
<br />.� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />H
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE LP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) � 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />a w July 9, 2011 b' �
<br />�� 23b. DATE SIGNED (MO., Day, Yr.) 23c. TIME OF DEATH �� k Y 24c. PRONOUNCED DEAD (Mo„ Day, Yr.J 24d. TIME PRONOUNCED DEAD
<br />� � Jul 12 2011 06:35 PM ° a<�
<br />� o �? °
<br />3tl. To the best of my knowiedge, death occurretl at the dme, tlate and place � K� 24e. On the hasls of exeminaflon andlar Inveatl8atlon, In my opinion tleath oceurred at
<br />-- �^ and due to the cau�(s) eteted (Signature and Titie) ._-- _--- - �_ . � p $ - _ the tlrtre. date and place and due ta the cauae(s) eteted. (Slpnawre and Tkle)
<br />c � - -
<br />� --- - -- - -- -- ..
<br />'' Ryan D. Crouch, DO '" ��
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED7 ZBb. WAS CONSENT GRANTED7
<br />� YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applieable H 28a is NO ❑ YES ❑ NO
<br />7. E, LE AND ADDRE F CERTIF ER (PH SI IAN, HYSI IAN IST , R NER S PH OR A ype or P8M
<br />Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />28a. REGI$TRAR'S SIONATURE �_ '� 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />July 12, 2011
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