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To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Lue James Allan Jr 2. SEX . t; 1, .`. ( ' 3. Male - - - • DATE DEATH (Mo., Day, Yr.) ` April ..9,`2010 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska Sa. AGE • Last Birthday ('' 60 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) April 18, 1949 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -60 -4225 8b. FACILITY -NAME (If not institution, give street and number) 1124 West 4th 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ® Other (Specffy)1124 West 4th 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 _ 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Greeley 9c. CITY OR TOWN Scotia 9d. STREET AND NUMBER 8241 Hwy 11 APT. NO. 8f. ZIP CODE I 68875 9g. INSIDE CITY LIMITS ❑ YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name Clenestell Denise Swift 11. FATHER'S -NAME (First, Middle, Last, Suffix) Lue James Allan Sr 12. MOTHER'S -NAME (First, Middle, Malden Surname) Clara E Nielson 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 10/23/1968 - 07/21/1970 14a. INFORMANT -NAME Lue James Allan III 14b. RELATIONSHIP TO DECEDENT Son 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Tracey Dietz 16b. LICENSE NO. 1328 16c. DATE (Mo., Day, Yr.) April 14, 2010 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park Crematory Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 18. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final a) Massive Acute Intracerebral Hemorrhage Immediate disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Hypertensive And Arteriosclerotic Cardiovascular Disease 6 Months any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE C ) (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS•Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 20.1F FEMALE: ❑ Not pregnant within past year 0 Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown If pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ® YES ❑ NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ® YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE a W 1 Y i 23a. DATE OF DEATH (Mo., Day, Yr.) .t, g h y E t < = 8 rc i O j9 C p 24a. DATE SIGNED (Mo., Day, Yr.) April 15, 2010 24b. TIME OF DEATH Approx. 09:30 AM 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH I 24c. PRONOUNCED DEAD (Mo., Day, Yr.) April 9, 2010 24d. TIME PRONOUNCED DEAD 10:27 AM 0 29d. To the best of my knowledge, death occurred at the time, date and place o S and due to the cause(s) stated. (Signature and Title) 24e. On the basis of examination and/or Investigation, In my opinion death occurred at the time, date and place and due to the causes) stated. (Signature and Title) Lynelle Homolka, Hall Deputy County Attomey 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? �26a. ❑ YES ❑ NO ❑ PROBABLY UNKNOWN ® HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES NO ® 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, HYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY A Lynelle Homolka, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, ORNEY) (Type or Print) 68802 128a REGISTRAR'S SIGNATURE f (� `YJDJt1Zf/V 288. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I April 19, 2010 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANO'M.) Mite* S RVIC S, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA,S #A DBP TMENT t HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR yfl 4t ' RECORDS y ^ t , DATE OF ISSUANCE 04/23/2010 LINCOLN, NEBRASKA STATE STATE OF NEBRASKA 201209685 S - ANLEY S COOPER , , ASSISANt EVPARTMET'i 'OF1-IFALTI-I -AND Hl1M,AYtI.SE ,' OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEIRf IIC ✓ PS.. is ^ ' ` •_ X 7 4 10 01052 CERTIFICATE OF DEATH } +sJ • • . }