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STATE OF NEBRASKA
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<br />WHEAI THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AIVD HLINIAN SERV',ICES, IT CERTIFIES
<br />a THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBKASKA f�EPARTN7ENT OF HEAtTH AND
<br />, HUMAN SERVICES, VITAL RECORDS OFFiCE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RC�ORDS �,� _y �
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<br />DATE OF ISSUANCE ,�����a��� �'' `��Y .
<br />STANLEY S: C13(�� t �� ;� s a ":'
<br />12/15i2011 2 0 � � � � � � .��. - �assrsF,�n�T sr,�����r�zs�r�� . ', � �
<br />�DEPAR'Ih'I�NT ��ALTI�f`AND i,y .
<br />LTNCOLN, NEBRASKA ,HU�?}IRf_S�RV�E� � � ,� ' ; ; �� .
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE� a �' � � �'� O4� 27
<br />CERTIFICATE OF DEATH ', '•: �'��:; '
<br />1.,DECEDENTS-NAME {flrat, Middle, Last, Sufl6c) 2. SIX c' ,' 3�:'OATE OFpEATH (lti+lo; Day, Yr.)
<br />Charles Danlel Mitchell Rev Male `'� r �ecembei 12, 2011
<br />4: Cil'Y AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AOE - Last BlRhday b. UNDER 1 YEAR Sc. UNDER 1 qAY .8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y�•) MOS. DAYS HOURS NUNS.
<br />Santa Maria, Cal'rfomia
<br />SOCIAL SECURITY NUMBER
<br />555
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<br />. FACILITY•NAME (H irot IrtsUtuUon, give street a
<br />Lakeview-A Golden Living Center
<br />, CITY OR TOWN OF DEATH (Include Zip Code) .
<br />Grand Island 68801
<br />80
<br />Ba. PLACE OF DEATH
<br />HOSPITAL � inpaqe�rt
<br />numbeh � ER/Outpatlerd
<br />❑ DOA
<br />OTH � Nursing HomeILTC
<br />❑ DeeedenCa Home
<br />❑ other (SFeeziTV)
<br />COUNTY OF DEATH
<br />Hall
<br />i. RESIDENCESTATE 8b. COUNTY 9c. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />I. STREET AND NUMBER e. APT. NO. 8f. 21P CODE 8g. INSIDE CITY UMITS
<br />304 East 13th St. 68801 � ves ❑ No
<br />la. MARITAL STATUS AT TIME OF DEATH � Mlar►led ❑ Nevar Married 10b. NAME OF SPOUSE (Flrst, Mtddle, Last, Suffbc) H wHe, glve maiden name
<br />❑ mamed, bu� separated ❑ v�ndowea ❑ onmrcea ❑ Unknown �ane Franc;�s Gregory
<br />, FATHER'S-NAME (FUSf, Middle, last, Suffbc) 12. MOTHER'S-NAME (First, Mlddle, Malden Sumame)
<br />Charles Ellsworth Mitchell Marielten Cook
<br />I. EVER IN U.S. ARMED FORCE37 Give dates oT service R Y�. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />n�, No, or un�c.> No Jane Frances Mitchell Wife
<br />f. METHOD OF DISP091TION 18a. EMBALMER�SIGNATURE 18b. LICENSE NO. 18c. DATE (MO., Day, Yr.)
<br />� sunai ❑ oormuon Chris McCoy 1181 December 15, 2011
<br />❑ Crematlon ❑ Errtombmeat 78d. CEMETERY, CREMATORY OR OTHER LOCATION CI7Y / TOWN STATE
<br />Q Removai ❑ Other (SP�KY)
<br />WesUawn Memorlal Park Cemetery Grand Island Nebraska
<br />'a. FUNERAL HOME NAME AND MAILIN� ADDRESS (Street, City or Town, State) 17b. 21p Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />I& PARI' L Errtaz the chatn ot aveirta dieea�s, iryurlee, a compUCatlon�that direWy caused the death. DO NOT eMer terminal evente such as cardfac artast,
<br />respiratary arrest, w vaMrlcWaz ftbri0atlon wFthout showing fhe e6ology. DO NOT ABBREVIATE. EMer only one ceuse on a One. Add edditlonal t6rea it newssary.
<br />IMMEDU►TE CAUSE:
<br />�aer�ow� ca,se �F� e) Pancreabc Cancer
<br />tli�ase w eondltlon reaultlaB
<br />�� �� DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequetrt�a0y ust cortdido�. B b)
<br />erry, Ieading to the cauee Ilated
<br />on Me a DUE TO, OR AS A CONSEQUENCE OF:
<br />F.nmr the UNDERlY1N6 CAUSE �)
<br />(dleease or Inlury that In(tiated
<br />��� �'� �� �') DUE TO, OR AS A CONSEQUENCE OF:
<br />� d)
<br />STATE
<br />!. PART p. OTHER SIGNIFlCANT CONDITIONS�Comlitlor� contrlbutlng to the death but not resulUng In the umlerfying cause gfvan in PART I. 79. WA9 MEDICAL EXAIV�NER
<br />Diabetes, HypeRension, Coronary Artery Disease, Colan Polyps OR CORONER CONTaCTEDT
<br />❑ YES � NO
<br />I. IF FENU4I.E: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJU 27a WA4 AN AUTOPSY PERFORMED?
<br />� Not pregna�d within past year � N�,� � HamidAe ❑ oma.�o��em
<br />p r� �e � ar a�rn � a�aa� � aa�m,� i� ❑ r�"ee. � ves � No
<br />� Not pTegnsnt, but pregnant wiWin 42 daye of deafh � Pedestrian 21 d. WERE AUTOPSY FlNDINGS AVAILA
<br />❑ Not Pres��►, but pre¢naM 4s daye m 1 yeaz eerore aeath ❑ swdae � coWd noe ne 6etemWrea � oueer �9peclfy) TO COMPLETE CAUSE OF DEA7H?
<br />� Unknmm B P�eB� wkhm Me pae! Year ❑ YES ❑ NO
<br />ta. DATE OF INJURY (MO., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, streeR iactory, offlee butiding, eorreWctlon eRe, etc. (SpeeHy)
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<br />❑ ves ❑ No I
<br />f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITYITOWN
<br />23a. DATE OF DEATH (Mo„ Day, Yr.)
<br />� December 12, 2011
<br />� } 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Z December 13, 2011 11:30 AM
<br />� � To the best M my Imowledge. deaTh oceurted at the 8me. date end Place
<br />� mM due m ttre eause(s) emma. (Signature am� Ttfle)
<br />Larry L. Hansen, MD
<br />�J YES � NO �] PROBABLY �J UNIOVOWN � �J YES
<br />WTIAE, TITL AND ADDRESS OF CERTIFIER (P YSIC , SI�/
<br />.arry L. Hansen, MD, 3016 West Faidley, Grand Island,
<br />REGISTRAR'S SIGNATURE ��r_ '� ,!� r
<br />11
<br />� Hospice Faciitty
<br />APPROXIMATEINTERVAL
<br />o�et to death
<br />2 Years
<br />onsetto death
<br />o�et to death
<br />onsetto death
<br />ZIP CODE
<br />24a. DATE 6lGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />���} 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TWIE PRONOUNCED DEAD
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<br />�� � 24& On the 6aels ot examfnatlon and/or Imeatlgadon, In my opinlon death ocCUrtetl at
<br />&$ rhe nme. ame �a P� �a a�e m ure c�te1 smma. �e�aua ana nue�
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<br />nSSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />� NO Not Applleable It 28a is NO ❑ YES ❑ NO
<br />, ORO ER S PH SIC A ORNE1� ype or rlrn)
<br />a. 68803
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<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 14, 2011
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