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1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Steven Gene Kirkpatrick 2. SEX Male 3. DATE OF DEATH '(Me., Day, Yr.) April 6, 2011 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE-Last Birthday (Yrs.) 53 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) November 4, 1957 MOS. DAYS HOURS MINS. 7.S0CIAL SECURITY NUMBER dal< 505- 82-7079 8a. PLACE OF DEATH HOSPITAL: ❑ Inpatient QIH®: XI NursingHome/LTC ❑ Hospice Facility 0 ER/Outpatient ❑Decedent's Home ❑ non ❑ Other (Specify) 8b. FACILITY -NAME (If not institution, give street and number) St. Francis Skilled Care 8c. C ITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 18d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY ORTOWN Grand Island 9d. STREET AND NUMBER 4314 Marian Rd 9e. APT. NO 91. ZIP CODE 68803 9g. INSIDE CITY LIMITS M YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH 31Married ❑ Never Married ❑ Married, but separated 0 Widowed 0 Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suety) If wife, give maiden name. Dayna Spencer 11. FATHER'S -NAME (First, Middle, Last, Suffix) Eugene Kirkpatrick 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Joan Roggy 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. (Yes, no, or unk.) NO 14e.INFORMANT -NAME Dayna Kirkpatrick 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION x ,3P ❑Burial ❑Donation Cremation 0 Entombment O Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Not Embalmed 16b. LICENSE NO. 1 6c. DATE (Mo., Day, Yr. ) April 6, 2011 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebr. Cremation Service Gibbon NE v+, 17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, Stale) Curran Funeral Chapel 3005 S. Locust St. Grand Island, Nebraska 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 r ''? respiratory arrest. or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. 1 - IMMEDIATE CAUSE: { onset B�IMEDIATECAUSE(Final (a 44 ( � ) 1...�7h Cam" � /r7� � I �� 170. Zip Code 68801 INTERVAL to death �-( "� Y � deem orcondlltonresuWng DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death d i p ' In death) Sequentially list conditions, if (b) any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death on roes, :`. Enter theUNDERLYWGCAUSE ,.,. - -, (dlaeaseor Injury that initiated ( the Wefts resifting indeath) . DUE TO, ORASA CONSEQUENCE OF: I onset to death t LAST 18. PART 0. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. I 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑YES la NO 20. IF FEMALE: ❑ Not pregnant within past year 0 Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death 0 Notpregnant, but pregnant 43 days to1 year before death rti 01.( nknownif pregnant within the past year 21a. MANNER OF DEATH MNatural ❑ Homicide 0 Accident Pending Investigation ❑ Suicide ❑ Could not be determined 21 b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑Passenger ❑ Pedeat'rien ❑ Other (Specity) 21c. WAS AN AUTOPSY PERFORMED? 0 YES XNO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETECAUSEOFDEATH? 0 YES 0N0 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22c. PLACE OF INJURY -A1 home, farm, street, factory, office building, construction site, etc. (Specify) 22d.INJURY AT WORK? ❑ YES 0 NO I'a`f7. 22e. DESCRIBE HOW INJURY OCCURRED 221. LOCATION OF INJURY • STREET a NUMBER, APT. NO. Cf YITOWN STATE ZIP CODE } .a< 23a. DATE OF DEATH (Mo., Day, Yr.) 41 `ep 'Lot/ a s- ' m a to 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIME OF DEATH m E s . a -1 23b. DATE SIGNED (Mo., Day, Yr. I - 42 -/( 23c.TIME OF DEATH /zyd Pm 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD i,t B f $ < 23d. To the best of my knowledge, death occur ad at the time, data and place and due to the cause s) at Signature and Title) • 8 i 24e On the basis of examination and/or investigation, In my opinion death occurred at B 3 the time, date and place and due to the cause(s) stated. (Signature and Title ) • 8 f _.. 25.DIOTOBA000 USE CONTRIB ETOTHEDEAT 0 YES U�0 0 PROBABLY 0 UNKNOWN i. 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S 5 Gary L. Settje M.D. 2116 28a, HAS ORGAN OR TISSUE DONATION SEEN CONSIDERED? 0 YES la410 PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) W. Faidley Ave. Suite 400 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑YES ENO Grand Island NE 68803 28a.REGISTRAR'SSIGNATURE 28b. DATE FILED BY REGISTRAR (Ms., Day, Yr.) APR 1 R 2011 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND tiUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASK P4RTMEF/? OrHIEALW AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VLtAL, RECORDS. DATE OF ISSUANCE APR 152011 LINCOLN, NEBRASKA 201303266 v STA9VCEY"S DOPER- Assis7 REGIITRAR DEPAkT14EN 0-1484L P HUMAi1N•$ER r STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT C ERTIFICATE OF DEATH 2 HHS-81 11/03 (55061)