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To be completed by: CERTIFIER ' To be completed/verified by: FUNERAL DIRECTOR 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Thomas William McIntyre 2. SEX , Male '3. DATE OF DEATH (Mo., Day, Yr.) - July 11,2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Nance County, Nebraska 5a. AGE • Last Birthday (Yrs.) 86 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATEOF BIRTH (Mo., Day, Yr.) February 9, 1927 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -38 -9734 8b. FACILITY -NAME (If not Institution, give street and number) 503 S. Broadwell Avenue 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 503 S. Broadwell Avenue 9e. APT. NO. I 9f. 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 r 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Jane Cooley 11. FATHER'S -NAME (First, Middle, Last, Suffix) John William McIntyre 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Inez Margaret McKelvey 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 04/18/1946- 03/26/1947 14a. INFORMANT -NAME Jane McIntyre 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) July 11, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Jacobsen - Greenway Funeral Home, 411 0 Street, PO Box 112, St. Paul, Nebraska 17b. Zip Code 68873 CAUSE OF DEATH (See instructions and examples) 1(1. 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 onset to death 5 Days respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Congestive Heart Failure After Acute Myocardial Infarction disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) any, leading to the cause listed online 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. IF FEMALE: ❑ Not pregnant within past year ❑ 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 InvesUgation ❑ Suicide ❑ Could determiner! 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? El YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE a W i E r E tj EI 23a. DATE OF DEATH (Mo., Day, Yr.) July 11, 2013 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) July 11, 2013 TIME OF DEATH I 23c. 03:10 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 4 0 9d. To the best of my knowledge, death occurred at the time, date and place c and due to the cause(s) stated. (Signature and Title) ' a Richard Fruehling, MD 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) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN I ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 12Se. REGISTRAR'S SIGNATURE /� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) July 15, 2013 DATE OF ISSUANCE 07/17/2013 LINCOLN, NEBRASKA STATE OF NEBRASKA 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 NEBRASKG4-.:DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL. RECORDS. 201305857 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. CDQPER ASSISTANT STATE REGISTRAR DEPARTMENT OF )IEALTH AND HLF(4I4N SERVICES' 13 02981