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STATE OF NEBRASKA ,
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ��A!{YNFA�II�,SER�liCES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WTTH THE NEBR,4Sf�' D NI�IV�'CT�"HEALTH AND
<br />HUMAN SERVFCES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEP0517"ORY FOR d�l�l"�L,�QS, .`' � 9
<br />� �„ � `' .,� .., e
<br />_ � �, a
<br />DATE OF ISSUANCE �� ,
<br />� �r� � , ,�
<br />10/04/2012 / s�,tA�t€f� S COOPER � . � �' �A
<br />� V � 2 U 0 / � �i ��TAN . �RE�ISTl�4}�a �
<br />D�,P/�R`fM�1t�•C� H�11L�1'ANQ = °�
<br />F � .
<br />LINCOLN, AIEBR,4SKA H�dI�N•SERVICES ` ,, ,,
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVI�ES�,, ' • .�� � � � �,� °. •' ,� � ,� 2 03626
<br />GERTIFICATE oF DEATt1 ' y � T �' • • ,; = �
<br />1. DECEDENT&NAME (Firaf, Mlddle, Last, Suftiz) 2. SDC ���' . DA`TE OF bEAFH (Mo., Day, YrJ
<br />Greg Lynn Miller Male �' ` Septetriber 27, 2012
<br />4. CRY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.►
<br />(Y�•) MOS. DAYS HOURS MIN9.
<br />Mitchell, South Dakota 57 January 5, 1955
<br />7. 50CIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />504-70-2028 OSPIT� ❑ ��atleM OTHER ❑ Nurairtg HomeILTC � Hospice Faciltiy
<br />Bb. FACILITY-NAME pf not Instltutlon, gNe street a� number) � ERIOutpaUent ❑ DeeedeM's Home
<br />�
<br />° Saint Francfs Medicat Center ❑ DOA ❑ aner �specity�
<br />c�
<br />� 8e. CITY OR TOWN OF DEATH p�lude Zip C�le) 8d. COUNTY OF DEATH
<br />c Grand Island 68803 Hall
<br />� 9a. RESIDENCESTATE 8b. COUNTY 8a CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />� 8d. STREET AND NUMBER e. APT. NO. 8L ZIP CODE 9g. INSIDE CITY LIMITS
<br />LL 223 Lakeside Drive 68801 ❑ v�s � No
<br />a�'
<br />.$ 10a. MARRAL 9TATUS AT TIME OF DEATH � Marri�i ❑ Never Married 10b. NAME OF SPOU3H (Flrat, Middle, Lest, Suftbc) it wHe, give malden rmme
<br />� ❑ Marrled, but separated ❑ Wldowed ❑ Dlvorced ❑ Unknown �ane Larson
<br />m
<br />� 11. FATHER'S•NAME (Flret, Middle, Laet, SuHlrz) 12. MOTHER'3-NAME (FUst, Middle, Malden Sumame)
<br />m Milo Miller lola Jackson
<br />°' 13. EVER IN US. ARMED FORCES? G(ve dates of serWce H Yea. 74a. INFORMANT-NAME 14b. RELATIONSHIP TO OECEDENT
<br />E
<br />$ (v�, No, or unic.) No Jane M(Iler Spouse
<br />,$ 15. METHOD OF DISPOSI710N 1Ba. EMBALMERSIGNATURE 16b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />� � Burtal ❑ Dormtlon Chrls MCCoy 1191 OCtober 3, 2012
<br />❑ Crematlon ❑ EntombmerR 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Remorai ❑ otr�er (speaty) St. Wilfrid's Catholic Cemetery Woonsocket South Dakota
<br />17a. FUNERAL HOME NAME AND MAlLNO ADDRESS (Street, CHy or Town, State) 77b. Zip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska ���
<br />CA SE OF EAT See instructions and exam les
<br />7B. �pART 1. Frrter the shain ot everrts-�dlaeaeee, NJuries, or eompllcatlona•thet dlrecUy cauaed the tleath. DO N0T e�rterterminat eve�rte aueh as caMac errest, ; APPROXIMATE INTERVAL
<br />respiratory srreat, or ventricutar BbriUatlon wtthout ehowing fhe edology. DO NOT ABBREVIATE Fster onty o�re cauae on e W�e. Add additlaml Ihrea iT ne�ry.
<br />IMMEDIATE CAUSE: ; o�wet W death
<br />imn+eowre cause �� a) Septic Shock
<br />disease or conditlon rasuiting
<br />�� p � ) DUE TQ OR AS A CONSEQUENCE OF: � onset to death
<br />SequeMlalty Iist contllUona, H b) Bacterial Sepsis
<br />anY. leadi� to the cause Iisfed '
<br />��� DUE TO, OR AS A CONSEQUENCE OF: 7 o�et to death
<br />EMerfhe UNDERLYINO CAU8E �) Left PleuPal Empyema
<br />(dieease or InJury that Initlated � �
<br />Ure eveMe resuidng In death) DUE TO, OR AS A CONSEQUENCE OF: � arreet to death
<br />� d)
<br />18. PART II.OTHER SIGNIFlCANT CONDITIONS�Comiitlo� contrtbuting to tFre death but rrot resulUng In the urMerlyt� cause gWen In PART 1. 18. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />� � YE3 ❑ NO
<br />W O. IF FEMALE: 27a. MANNER OF DEATH 27b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMEDT
<br />� � N�P�e�u.mrun v�r� � n� � Honudaa ❑ om�eo��or � res ❑ NO
<br />W PregnaM et Ume of deatli � Paeeenger
<br />� Q eat � peWqeM � PenEing Imestlgatlon
<br />a � Not pregnaM, but pregnant wlthln 42 daya oi deafh guidde CoWd imt be determined � P��80 Z�d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />❑ ❑ TO COMPLETE CAUSE OF DEATH?
<br />� � Not P�B�R but P�eB� 43 daye to 1 year beMre death ❑ ou�. �sa�r� � ves ❑ No
<br />m � Unlmownl(pregnantwlthlnthelmatYear
<br />°' Yla. DATE OF INJURY (Mo., Day, Yr.) Z2b. TIME OF WJURY ZZe. PLACE OF INJURY•At home, tarm, etreet, faetory, oftice butiding, coiretructlon alte, etc. (Speci(y)
<br />E
<br />$
<br />� 22d. INJURY AT WORK? 22e. DESCWBE HOW INJURY OCCURRED
<br />H
<br />❑ YES ❑ NO
<br />22f: LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo, Day, Yr.) 24a. DATE SIGNED (MO., Day, Yr.) 246. TIME OF DEATH
<br />.� s�� September 28, 2012 12:40 AM
<br />� �� 23b. DATE SIGNED (Mo„ Day, Yr.) 23c. TIME OF DEATH �� k 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />o �< o Se tember 27, 2012 12:40 AM
<br />� . To the best M rtry Imowledge, death xwrted at the tlme. date end place � 24e. On Ne basie of exeminat�on andfw Imestigatlon, In my opinlon death ocwrted at
<br />�- end due W fhe cauea(e) s�ed• (Signature eiM Tftle) .$ �� the dme� date and place mM due M tlre cauee(e) efated. (Signature and Title)
<br />~� ~ g s Sarah Carstensen, Hall Deputy County Attomey
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATHT 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED7 28b. WAS CONSENT GRANTED4
<br />❑ YES ❑ NO ❑ PROBABLY � UNKNOWN ❑ YES ❑ NO Not Applleable H 28a is NO � YES ❑ NO
<br />27. TIT D OF C I IE ype or P rrt
<br />Sarah Carstensen, Hatl Depuiy County Attomey, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />28a. REGISTRAR'S SIGNATURE �` �^� 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />October 2, 2012
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