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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Burnell Allen Cameron 2. SEX , Male '3.DATEOF DEATH (Mo., Day, Yr.) - December 18, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Hampden, North Dakota 5a. AGE - Last Birthday (Yrs.) 77 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) November 9, 1936 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 501 -34 -3455 8b. FACILITY -NAME (If not Institution, give street and number) Park Place -A Golden Living 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 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2409 W. Phoenix e. APT. NO. r 9f. ZIP CODE I 68803 9g. INSIDE CITY LIMITS IA 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 Susan Peterson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Victor Cameron 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) Grace Elfman 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 07/07/1955 - 05/22/1957 14a. INFORMANT -NAME Susan Cameron 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.) December 20, 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 OF DEATH (See instructions and examples) _ To be completed by: CERTIFIER 1e. PART I. Enter the chain of events - diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death 6 Months 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) Metastatic Adenocarcinoma Lung disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: • onset to death Sequentially list conditions, if b) any, leading to the cause listed on Inc I 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 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART 1. Hypertension,atrial Fibrillation,coronary Artery Disease ,obstructive Lung Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 20. IF FEMALE: ❑ Not pregnant within 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 ❑ 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 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. 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 g Y 6 z 23a. DATE OF DEATH (Mo., Day, Yr.) December 18, 2013 I. f g Y K t O W B Z $ ` o 3 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) December 20, 2013 23c. TIME OF DEATH I 07:07 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD < 0 3d. To Inc best of my knowledge, death occurred at the time, date and piece Y antl due to the causes) stated. (Signature and Title) s Ryan D. Crouch, DO 24e. O 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 Tine) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? M YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 28a. 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 Print Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 128a . REGISTRAR'S SIGNATURE / " 28b. DATE FILED BY REGISTRAR (MO., Day, Yr.) I December 30, 2013 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH A'ND'HUM SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKI4.bEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR. VITAL• .RECORDS 1 DATE OF ISSUANCE 01/02/2014 STATE OF NEBRASKA 201 40 0 7 61 =StAN Y ` COOPER - ' =ASST S REGISTRAR= yDEPA ALTH MID LINCOLN, NEBRASKA ' M4/MAN SERVICES - � � 4 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVJOIrS: ,, ri r' •`fir ,� dr y CERTIFICATE OF DEATH • • -,13 05630