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r To Be Completed/Verified by: FUNERAL. DIRECTOR
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Patrick Edward Maginnis
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo.,Day,Yr.)
<br />August 20, 2013
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kimball, Nebraska
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />52
<br />Sb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />9. DATE OF BIRTH (Mo., Day, Yr.)
<br />February 20, 1961
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7, SOCIAL SECURITY NUMBER
<br />506 -94 -4293
<br />8a. PLACE OF DEATH
<br />HOSPITAL: j npatlent OTHER: ❑ Nursing HomeILTC ❑ Hospice Facility
<br />8b. FACILITY -NAME (t not hwtltution, give street and number)
<br />Nebraska Medical Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68198
<br />° ER/Outpatient ❑ Decedent's Home
<br />0 DOA 0 0tI S p 0 ►
<br />-
<br />8d. COUNTY OF DEATH
<br />Douglas
<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 />2904 Circle Drive
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Manied ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />1011. NAME OF SPOUSE (First, Middle,
<br />Susan L Traudt
<br />9e APT. NO.
<br />Last, Suffix) If
<br />9f ZIP CODE
<br />68801
<br />wlte, give maiden name.
<br />eg INSIDE CITY LIMITS
<br />® Yea ❑ No
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Edward Maginnis
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Marilyn Garrard
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk-) No
<br />14e. INFORMANT -NAME
<br />Susan L Maginnis
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />D crumatlan phonation ea
<br />°Removal , °olher(awctltl
<br />16a. EMBALMER - SIGNATURE
<br />1611. UCENSE NO.
<br />L 9./
<br />18c. DATE (Mo., Day, Yr.)
<br />August 23, 2013
<br />1lid. CEMETERY, CREMATORY OR OTHER LOCATION CITYITOWN STATE
<br />Westlawn Cemetery Grand Island 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 />1�7b. Zip Code
<br />68801
<br />Ir
<br />W
<br />K
<br />W
<br />V
<br />I ❑Unknown
<br />a
<br />E
<br />I
<br />CAUSE OF DEATH (See instructions and examples)
<br />1e.
<br />PANT I Enterae vw, rs
<br />ae - diseases. Wea ge, or compliations- seastractly ooNOTe nt ertsrminalsmelt suchacardiacanus% APPROXIMATE INTERVAL
<br />respiratory wrest, or ventricular Mandan without showing me etiology. 00 NOT ABBREVIATE Enter Only necessary.
<br />one rause on a line. Add additional lines Irnecry.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE disease C st on (Final /
<br />In d or eondilion resulting a) ( ! (/ /s ue
<br />In death) j Fa t/I C/
<br />DUE TO, OR A CONSEQUENCE OF:
<br />//`` onset to death
<br />Est conditions, ( (' /- ( .o ! J c
<br />Sequenn b) `% 1 / (�. S u
<br />try, leading g to the cause listed
<br />online °' DUE TO, OR AS A CONSEQUENCE OF: / �// / i L_I I � onset to death
<br />-
<br />Enter t» UNDERLYING CAUSE c) (r�0
<br />(disease or injury that initiated U ( IC. / / -r ® - ,fe
<br />r G /'
<br />j �
<br />IA,* went. „awing to death) DUE TO, AS A CONSEQUENCE OF onset to death
<br />LAST
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions ti conb butlng to the death but not resulting M to underlying cause given in PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />,
<br />❑ YES 10
<br />"
<br />20.1F FEMALE: -
<br />❑ Not pregnant within past year
<br />❑Pregnant at time of death
<br />ONot Pregnant. bud Pregnant within 42 daYS of death
<br />° Not Pregnant. but Pregnant 43 days to 1 year before death
<br />if pregnant within the past year
<br />-�-
<br />21a. MANNER OF DEATH
<br />�atu I ❑ Homicide
<br />resident ❑ Pending investigation
<br />❑ Suicide ❑ Could not be determined
<br />2111. IF TRANSPORTATION INJURY
<br />❑ DavadOperator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21o. WAS AN AUTOPSY PERFORMED?
<br />❑ YES
<br />21tl. WERE AUTOPSY INDINGS AVAILABLE
<br />TO YEMPLE TEY TE CAUSE OF DEATH?
<br />❑YES ❑ NO
<br />22a DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22e. PLACE OF INJURY -At home, farm, street, factory, office building, conatrueton ate, etc. (SpaWy)
<br />2'2d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJU OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITYITOWN - STATE ZIP CODE
<br />W
<br />A -
<br />i 23b.
<br />a V
<br />8
<br />23a. DATE OF 114 (Mo., r.)
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<br />� a ' A i t
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<br />a
<br />S E to a z
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<br />V $
<br />248. DATE SIGNED (Mo., Day, Yr.)
<br />2411. TIME OF DEATH
<br />m
<br />A�TE 0 (Mo., Da Yr.)
<br />D
<br />Z mo(/
<br />1 J I
<br />230, T1ME OI ; TH
<br />1 Gn
<br />.d date
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />t , 23d. To beat of , death occurred at tin Wne and plan
<br />and dw car ) stated. (Signature and Title)
<br />Flo Yf/f
<br />240 bash atexamination pace due to nddlur I cause, in my opinion death occurred
<br />at
<br />at the a time, deb and d plan and d to the the cause(s) stated. (Signature and TItle)
<br />25. DI TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES 1;a1‘10 ❑ PROBABLY 0 W4$. t
<br />2$ L yea$ ORGAN OR
<br />YES
<br />y f 1
<br />TISSUE TION BEEN CONSIDERED?
<br />NO
<br />261 WAS CONSENT GRANTED?
<br />Not Applicable t 26a le NO ❑ YES ❑ NO
<br />27. ME, TITLE AND - ESS CERT)f1ER1Typee or pdn3) - .d _ -
<br />s
<br />P
<br />2�e STRAW-- = NA RE
<br />Al -�
<br />2811 DATE FILED BY REGISTRAR Into.. Day, Yr.)
<br />A 1201
<br />Date Issued:
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />3 52352
<br />.
<br />This certifies this do is, to be 'a tau cppy.ofan original record on file with Vital Statistics, Douglas
<br />County Health Dept., .; t : ' Nebths C s s. ed copies must have a raised seal in the area to the left.
<br />Reproduction of this grad certificate' are-n6 gal copies.
<br />2:1
<br />ReaictrMr� /L1�•3L- *�""�i,� • ..i+
<br />201307149
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