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To be completed /verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Doyle Ray Hunt 2. SEX Male 3. DATE'OF DEATH (Mo., Day, Yr.) November 8, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Worland, Wyoming 5a. AGE - Last Birthday (Yrs.) 81 Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) May 28, 1932 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 520 -30 -4429 8b. FACILITY -NAME (If not Institution, give street and number) 928 E. Sunset Avenue 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Horne ❑ 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 928 E. Sunset Avenue 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS lid 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 Dorothy May Buckle 11. FATHER'S -NAME (First, Middle, Last, Suffix) Vernon Hunt 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Elta Wortham 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 01/06/1951 - 01/05/1955 14a. INFORMANT -NAME Dorothy May Hunt 14b. RELATIONSHIP TO DECEDENT Spouse 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.) November 11, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) I To be completed by: CERTIFIER 18. 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, r APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Stage 4 Adenocarcinoma Lung disease or condition resulting onset to death 1 Year in death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death Sequentially list conditions, if b) 1 any, leading to the cause listed 1 1 line on a. DUE TO, OR AS A CONSEQUENCE OF: ; onset to death Enter the UNDERLYING CAUSE c) i (disease or injury that initiated ; the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) 1 1 1 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 I 20. IF FEMALE: ❑ Not pregnant within past year 0 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 it pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 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 & NUMBER, APT.NO. CITYYTOWN STATE ZIP CODE E W i I r E ti E 23a. DATE OF DEATH (Mo., Day, Yr.) November 8, 2013 a [a i € y E a. < z : i W is z O 8 0 5 ~ c s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) November 11, 2013 23c. TIME OF DEATH , 08:55 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD u R 0 3a. To INC best of my knowledge, death occurred at the time, date and place o w and due to the cause(s) stated. (Signature and Title) Ryan D. Crouch, DO 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? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE - _iO�(J� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) November 12, 2013 DATE OF ISSUANCE 11/18/2013 LINCOLN, NEBRASKA STATE OF NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 201310049 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH4tNb H'// iAN, SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKARE,RARt'TPIENT'OF HEALTH AND HUMAN SERVICES, V I T A L RECORDS O F F I C E , WHICH I S T H E LEGAL DEPOSITORY FOR V I T A L REE11 S R STANLEY v COPPER ' • ASSISTA STATE REGISTRAR DEP00TM T dF`HCAL7 AND H(I/M><tp. SERVICES • 13 04828