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To be completedNerified by: FUNERAL DIRECTOR <br />1 <br />1. DECEDENTS-NAME (First, Middle, Last, Suffix) <br />Mylus Edward Robison <br />2. SEX. <br />Male <br />3: DATE-OF DEATH (Mo., Day, Yr.) <br />April 1 2013 <br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH <br />Cozad, Nebraska <br />5a. AGE • Last Birthday <br />(Yrs.) <br />81 <br />51). UNDER 1 YEAR <br />5c. UNDER 1 DAY <br />6. DATE OF BIRTH (Mo., Day, Yr.) <br />July 22, 1931 <br />MOS. <br />DAYS <br />HOURS <br />MINS. <br />7. SOCIAL SECURITY NUMBER <br />506 -36 -0236 <br />8a. PLACE OF DEATH <br />HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility <br />8b. FACILITY-NAME (If not Institution, give street and number) <br />Golden LivingCenter -Grand Island Lakeview <br />❑ ER/Outpatient ❑ Decedent's Home <br />❑ DOA ❑ Other (Specify) <br />8c. CITY OR TOWN OF DEATH (Include Zip Code) <br />Grand Island 68801 <br />8d. COUNTY OF DEATH <br />Hall <br />9a. RESIDENCE-STATE <br />Nebraska <br />9b. COUNTY <br />Hall <br />9c. CITY OR TOWN <br />Grand Island <br />9d. STREET AND NUMBER <br />1405 West Hwy 34 <br />e. APT. NO. <br />502 <br />9f. ZIP CODE <br />68801 <br />9g. INSIDE CITY LIMITS <br />® YES ❑ NO <br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married ❑ Never Married <br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown <br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name <br />Constance Mae Johnson <br />11. FATHER'S -NAME (First, Middle, Last, Suffix) <br />George E Robison <br />12. MOTHER'S -NAME (First, Middle, Maiden Surname) <br />Bessie Byerley <br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. <br />(Yes, No, or Unk.) Yes 07/16/1952 - 06/19/1954 <br />14a. INFORMANT -NAME <br />Constance Mae Robison <br />14b. RELATIONSHIP TO DECEDENT <br />Spouse <br />15. METHOD OF DISPOSITION <br />® Burial ❑ Donation <br />❑ Cremation 0 Entombment <br />❑ Removal ❑ Other (Specify) <br />16a. EMBALMER-SIGNATURE <br />Tracey Dietz <br />16b. LICENSE NO. <br />1328 <br />16c. DATE (Mo., Day, Yr.) <br />April 22, 2013 <br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE <br />Westlawn Cemetery Grand Island Nebraska <br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) <br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska <br />17b. Zip Code <br />68801 <br />CAUSE OF DEATH (See instructions and examples) <br />To be completed by: CERTIFIER <br />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, <br />APPROXIMATE INTERVAL <br />onset to death <br />Days <br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. <br />IMMEDIATE CAUSE: <br />IMMEDIATE CAUSE (Final a) Severe Sepsis <br />disease or condition resulting <br />In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death <br />Sequentlally list conditions, it b)Aspiration Pneumonia Days <br />any, leading to the cause listed <br />line <br />on a. DUE TO, OR AS A CONSEQUENCE OF: onset to death <br />Enter the UNDERLYING CAUSE c) Small Cell Lung Cancer Months <br />(disease or injury that Initiated <br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death <br />LAST d) <br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death ' . d resulting In the underlying cause given In PART I. <br />Chronic Myelocytic Leukemia <br />19. WAS MEDICAL EXAMINER <br />OR CORONER CONTACTED? <br />❑ YES 0 N <br />20. IF FEMALE: <br />❑ Not pregnant within past year <br />❑ Pregnant at time of death <br />❑ Not pregnant, but pregnant within 42 days of death <br />❑ Not pregnant, but pregnant 43 days to 1 year before death <br />❑ Unknown if pregnant within the past year <br />21a. MANNER OF DEATH <br />® Natural ❑ Homicide <br />❑ Accident ❑ Pending Investigation <br />❑ Suicide ❑ Could determined <br />21b. IF TRANSPORTATION INJURY <br />❑ Driver /Operator <br />❑ Passenger <br />❑ Pedestrian <br />❑ Other (Specify) <br />21c. WAS AN AUTOPSY PERFORMED? <br />❑YES ® NO <br />21d. WERE AUTOPSY FINDINGS AVAILABLE <br />TO COMPLETE CAUSE OF DEATH? <br />❑ YES ❑ NO <br />construction site, etc. (Specify) <br />22a. DATE OF INJURY (Mo., Day, Yr.) <br />22b. TIME OF INJURY <br />22c. PLACE OF INJURY -At home, <br />farm, street, factory, office building, <br />22d. INJURY AT WORK? <br />❑ YES ❑ NO <br />22e. DESCRIBE HOW INJURY OCCURRED <br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE <br />.t W <br />1 g } <br />u E <br />23a. DATE OF DEATH (Mo., Day, Yr.) <br />April 17, 2013 <br />To be completed by <br />CORONER'S PHYSICIAN <br />or COUNTY ATTORNEY <br />ONLY <br />24a. DATE SIGNED (Mo., Day, Yr.) <br />24b. TIME OF DEATH <br />23b. DATE SIGNED (Mo., Day, Yr.) <br />April 23, 2013 <br />23c. TIME OF DEATH <br />I 05:05 AM <br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) <br />24d. TIME PRONOUNCED DEAD <br />0 4 0 3d. To the best of my knowledge, death occurred at the time, date and place <br />2 c and due to the cause(s) stated. (Signature and Title) <br />2 Travis S. Hageman, MD <br />24e. On the basis of examination and /or investigation, In my opinion death occurred at <br />the time, date and place and due to the cause(s) stated. (Signature and Title) <br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO <br />266. WAS CONSENT GRANTED? <br />Not Applicable if 26a is NO ❑ YES ❑ NO <br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print <br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 <br />128a. REGISTRAR'S SIGNATURE / A <br />, •� /`t Y L (gip -Rl�,� <br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I <br />April 24, 2013 <br />STATE OF NEBRASKA <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTId'A D IIFI4AI� IT CERTIFIES <br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAS EMPTI4L IT irgAjTH AND <br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOP -VI AL RE C S • , t' ' , <br />DATE OF ISSUANCE <br />04/29/2013 <br />201 305475 . <br />LINCOLN, NEBRASKA <br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICE'S' 01 801 <br />CERTIFICATE OF DEATH <br />STANLEY CAPER <br />ASSISTAN )ST4T ` REG STRAR <br />DEPARTMENT OF HEALTH ANd , <br />HUMAN' SERVICES ?' <br />