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--- 1. To be completed by: CERTIFIER To be completedlerifled by: FUNERAL DIRECTOR 1 DECEDENT'S -NAME (First, Middle, Last, Suffix) Thomas M Conlon 2. SEX • y t t Male .3. DATE OF DE/14H (Ma., Day, Yr.) - August2, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Kansas City, Missouri 5a. AGE - Last Birthday (Yrs.) 67 5b. UNDER 1 YEAR 5c. UNDER 1 DAY '6 DATE OF BIRTH (Mo., Day, Yr.) August 17, 1946 MOS. DAYS I HOURS MINS: 7. SOCIAL SECURITY NUMBER 505- 60-9834 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center 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 68803 I 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 8b. COUNTY Hall 9c. CITY OR TOWN Grand Island 819 S. Stuhr Rd r e. STREET AND NUMBER e. APT. NO. 8f. 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 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) ff wife, give maiden name Faye L Kumm 11. FATHER'S -NAME (First, Middle, Last, Suffix) Frank Conlon 12. MOTHER'S -NAME (First, Middle, Malden Surname) Edna Kendall 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Faye L Conlon 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSfTION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Not Embalmed 18b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) August 28, 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) Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART 1. Enter the chain of events - dlseases, Injuries, or compnadontathat directly awed the death. DO NOT enter teminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one awe on a Nne. Add additional lines If necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final a) Hemorrhagic Stroke 8 Days disease or condition moulting in death) DUE TO, OR AS A CONSEQUENCE OF: t ileffel Sequentially Net conditions, if b) any, leading to the cause listed on line 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 eewe given in PART 1. Diabetes Mellitus, Coronary Artery Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED'? ❑ YES ® NO 20. IF FEMALE: ❑ Not pregnant wlthhr 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 on ❑ Accident ❑ Pending hwertlgati Suicide cows determined ❑ ❑ 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ a Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? El YES 0 N 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (*mail) 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8, NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE >; ik t z 23a. DATE OF DEATH (Mo., Day, Yr.) August 28, 2013 >t• 1 Y < o f e ig i 5 E 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) August 28, 2013 23c. TIME OF DEATH I 02:48 AM 24c. PRONOUNCED DEAD4MO., Day, Yr.) 24d. TIME PRONOUNCED DEAD C ad. To the best of my knowledge. death occurred at the time, dab and plea E and due to the cause(s) stated. (Signature and Title) 1 David R. Colan, MD 24e. On the basis examination and/or Investigation, In my opinion death occurred at tin Sbne, date and place and due b tin cauaWs) stated. (Signature and Ttlb) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ISSUE DONATION BEEN CONSIDERED? 0 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print David R. Colan, MD, 729 North Custer Avenue, Grand Island, N 803 e- , 28a. REGISTRAR'S SIGNATURE A f G 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I September 3, 2013 • STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL77j A {{� S, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE N! P4 P RT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR id Ai. ECd 6.&.: 1 ) DATE OF ISSUANCE OT AlLiEY S COOPER 1 201308804 ; S TAN�i TArtaREGISTRARi�'. QL1RM.1 .QF /LTH AN it i ; k� LINCOLN, NEB 09/05/2013 NEBRASKA HLMWANERVICES r STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEkVI4§ CERTIFICATE OF DEATH ,R `4 #� , ; 13 63726 •