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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Augustus William Clark 2. SEX '° , ' Male ., 4 - 13. DATE OF DEATH (Mo., Day, Yr.) May 29, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Philadelphia, Pennsylvania 5a. AGE • Last Birthday (Yrs.) 93 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.) February 21, 1920 MOS. DAYS HOURS : MINS. 7. SOCIAL SECURITY NUMBER 207 -05 -9360 8b. FACILITY -NAME (11 not institution, give street and number) Wedgewood Care Center 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpauent ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH I Hall 9a. RESIDENCE STATE Nebraska 9b. COUNTY I Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 219 West 15th Street 9. APT. NO. r 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 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Lois Zig afoos 11. FATHER'S -NAME (First, Middle, Last, Suffix) Augustus W Clark 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Florence Witman 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 04/06/1942 - 12/06/1945 14a. INFORMANT -NAME Patricia Deines 14b. RELATIONSHIP TO DECEDENT Daughter 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.) May 30, 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) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OVDEATH (See instructions and examples) To be completed by: CERTIFIER 18. PART 1. Enter the chain of events- -diseases, injuries, or complicatlons4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, . APPROXIMATE INTERVAL only one cause on a line. Add additional lines If necessary. onset to death Hours respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Cardiopulmonary Arrest disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: . onset to death Sequentially list condwoas,if b) Chronic Obstructive Pulmonary Disease Years any, leading to the cause listed on line a DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Atrial Fibrillation Years (disease or injury that Initiated Inc events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST - d) 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting In the underlying cause given In PART 1. Hip Fracture 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 1E1 NO 20. IF FEMALE: ❑ Not pregnant within past year at oeath - Pregnant time of d ❑ P ❑ 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 investigation 0 Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES [531 NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 122b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE ,r d z 23a. DATE OF DEATH (Mo., Day, Yr.) May 29, 2013 3' e, ' .8 W p g 5 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) June 3, 2013 123c. TIME OF DEATH 03:40 PM 24c PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 0 9d. To Inc best of my knowledge, death occurred at the time, date and Piece E g and due to the cause(s) stated. (Signature and Title) 7 Kenneth Vettel, MD 24e. On Inc 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 ❑ YES f7 • j 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO 0 YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER orPri n Kenneth Vettel, MD, 2116 W Faidley #400, Box 9802, Grand Isla Nebraska, 68803 28a. REGISTRAR'S SIGNATURE /)1, '- /�� - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) June 3, 2013 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALT1-4 THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR4A HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR" N DATE OF ISSUANCE 06/05/2013 CERTIFICATE OF DEATH 20 1308819 � AS ST T TATE F DEPARA All 0MEALTN"AND LINCOLN, NEBRASKA : HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE *' ES, IT CERTIFIES ,_TH AND 13 02407