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To Be CompletedNerlfled by: FUNERAL DIRECTOR I
<br />1. DECEDENTS -NAME - (First, Middle, Last, Suffix)
<br />Norman Joseph Hinze
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo.,Day,Yr.)
<br />September 29, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Burwell, Nebraska
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />69
<br />Sb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />May 13, 1942
<br />MOB.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />506-50-0850
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OHERI ❑ Nursing HomeILTC ❑ Hospice Facility
<br />8b. FACIUTY -NAME (I not Institution, give strew and number)
<br />VA Medical Center
<br />❑ ER/Outpatient 0 Decedent's Home
<br />❑ DOA ❑ Other(Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68105
<br />ed. COUNTY OF DEATH
<br />Douglas
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />Sb. COUNTY
<br />Hall
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />ed. STREET AND NUMBER •
<br />212 West 20th Street
<br />9e. APT. NO.
<br />SL ZIP CODE -
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />El Yea ❑ No
<br />1ea. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never M
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suf lx), wire, give maiden name.
<br />Peggy Porter
<br />11. FATHERS NAME (First, Middle, Last, Suffix)
<br />Melvin L Hinze
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Margaret M Schmeits
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service I Yea.
<br />(Yes, No, orUnk.) Yes 02/08/1964- 02/01/1966
<br />14a. INFORMANT•NAME
<br />Peggy Hinze
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />1c. DATE (Mo., Day, Yr.)
<br />October 3, 2011
<br />1& METHOD OF DISPOSITION
<br />�
<br />®I ['Donation
<br />['Cremation Diatom
<br />['Removal D0tMr(Spes6y)
<br />lie. EMBALMER- SKNNATIRE
<br />186. UCENSE NO.
<br />/ y) O
<br />1 . CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />St. Libory's Catholic Cemetery St. Libory Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. ZIp Code
<br />68801
<br />D I • To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />is. PART I. Edarthe cede a teffe . diseases, Injuries. or compilations that directly caused the death. DO NOT ent.rtamanel events such as cardiac arrest APPROXIMATE INTERVAL
<br />rapiMory and, or ventricularebdeaees without showMg the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines If neasaery.
<br />• IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final i 1-i G Gf p n • W - 3 ° ^^
<br />dleeaseorcOntlonresulting a) A� 1C P LEe0ITJ 6 ITN /1SSF i1JA76?) lNTRA,v14 IJ IT1`U' CC
<br />in ) 1
<br />• DUE TO, OR AS A CONSEQUENCE OF: ,S14J1..A11 `J OA- J/-A+ Tj oat onset to death
<br />Sequentially list conditions, If ^(/ e ACE /�
<br />any, leading to the cause listed b) • 1 e +` •alte r4 1=17.7 f bR 4 ( ACE OF 6 4"1-L t I L /U/.)3
<br />on line e. DUE TO, OR AS A CONSEQUENCE OF: .1 . , onset to death
<br />Enter the UNDERLYING CAUSE C) ii CA L CuLo. S C H o - LE C.7 ST (...c / ac IT H P OSS I/3 Le s EPS IS
<br />(disease or Injury that initiated I
<br />the evens melting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST r e nic Lymphol d u�.�,.
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDmONS-Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />D YES ,Q9, NO
<br />20. IF FEMALE:
<br />❑Not pregnant width% 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 death
<br />[]Unknown If pregnant within the past year
<br />215. MANNER OF DEATH
<br />ia,Natural ❑ Homicide
<br />� ❑ Accident ❑ Pending Investigation
<br />❑ Suicide . ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJU
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES IB NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />COMPLETE CAUSE OF DEATH?
<br />DYES
<br />YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />4 22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building. construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED -
<br />22f. LOCATION OF INJURY - STREETS NUMBER. APT. NO. .. CITYWtONN STATE ZIP CODE
<br />td
<br />a
<br />HJ
<br />I t�Q t
<br />o
<br />23s. DATE OF DEATH Day, .)
<br />0 C j "t 9 Z 0) t '•
<br />Z
<br />.a. 2 Z
<br />3-O
<br />E 3 i <z
<br />8 tt u a O
<br />2 z O
<br />O
<br />FgV •
<br />0
<br />245. DATE SIGNED (Mo., Day, Yr.)
<br />246. TIME OF DEATH
<br />m
<br />235. DATE ED (Mo., Day, Yr.)
<br />(03 1 )-0 ii
<br />23c. TIME OF DEATH q
<br />- Ovm
<br />24c. PRONOUNCED DEAD (Mo., Day,'Yr.)
<br />3
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />23d. To the best of my knowledge, death occurred al the time, date and place
<br />and due to use(s) stated. (Signature and MN
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred
<br />at the time, date and place and due to the cause(s) stated. (Signature and Ms)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 126a.
<br />0 mown ❑YES 0 NO PROBABLY mown
<br />HAS ORGAN OR TISSUE gONATION BEEN CONSIDERED?
<br />I l D YES
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />N A RCS H 4. _ b. u#-A44 • . , t4 E> , ; tat 10001umeit, Ave_ 0 ,rha -1 N L 4 105
<br />28s. REGISTRAR'S SIGNATURE ✓
<br />- � elm'
<br />28b. DATE FILED BY
<br />kCT 'I
<br />REGISTRAR (Mo., Day, Yr.)
<br />1 2011;
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />2011 _ CERTIFICATE nF r)FATH
<br />,44946
<br />This certifies this document'to be a true c6py ofwal :original record on file with Vital Statistics, Douglas
<br />County Health Dept, Omaha, Nebraska. ` Certified-copies must have a raised seal in the area to the left.
<br />r..
<br />Reproduction of this green certificate areant)t 1ega copies.
<br />Date Issued. 201 - Registrar: sC t4il;•
<br />201306399
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