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To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Michael Philip Haines 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) January 17, 2011 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Denver, Colorado 5a. AGE - Last Birthday (Yrs.) 58 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) February 24, 1952 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 523 -78 -5870 8b. FACILITY -NAME (If not Institution, give street and number) 3712 W. Hwy 30 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 3712 W. Hwy 30 19e. APT. NO. I 8f. ZIP CODE I 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed', ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Lenetta Ohlert 11. FATHER'S -NAME (First, Middle, Last, Suffix) Jesse P Haines 12. MOTHER'S -NAME (First, Middle, Malden Surname) Clara Henry 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 07/18/1972 - 12/06/1973 14a. INFORMANT -NAME Lenetta Haines 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. K EMBALMER-SIGNATURE vin Wood 16b. LICENSE NO. 1325 16c. DATE (Mo., Day, Yr.) January 22, 2011 16d. W EMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE egert Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS Livingston - Sondermann Funeral !Home, (Street, City or Town, State) 601 N. Webb Road, Grand Island, Nebraska 17b. Zip Code 68803 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 directlylaused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Immediate 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: IMMEDIATE CAUSE (Final a) Heart Attack disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: - onset to death Sequentially list conditions, if b) Obesity Years any, leading to the cause listed line on a. DUE TO, OR AS Enter the UNDERLYING CAUSE C) (disease or Injury that initiated A CONSEQUENCE OF: onset to death the events resulting in death) DUE TO, OR AS LAST d) A CONSEQUENCE OF: onset to death 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. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of ❑ Not pregnant, but pregnant 43 days to 1 year ❑ Unknown if pregnant within the past year 1 death qe fore death 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 El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE W 1 >. Eu - ' 23a. DATE OF DEATH (Mo., Day, Yr.) S ., W I I > E `Z a o $ W o G p 8 3 24a. DATE SIGNED (Mo., Day, Yr.) January 21, 2011 24b. TIME OF DEATH Approx. 09:30 AM 23b. DATE SIGNED (Mo., Day, Yr.) 123c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) January 17, 2011 24d, TIME PRONOUNCED DEAD 12:30 PM 8 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 c a 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 cause(s) stated. (Signature and Title) Robert Cashoili, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ❑ YES ®NO Not Applicable If 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, I Robert Cashoili, Hall Deputy County Attorney, 231 HYSICIAN ASSISTANT, CORONER'S PHYSICIAN COUNTY A ORNEY) (Type or Print) S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 128a . REGISTRAR'S SIGNATURE 46 _ - - �WV 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I January 21, 2011 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 01/28/2011 STATE OF NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 201302451 ASS STATE REGISTRAR DEPARTMENT OF HEALTH AND LINCOLN, NEBRASKA HUMAN SERVICES 11 00193 CERTIFICATE OF DEATH